JV 28 points

Mental Health Charter for SHAL  Nov 2021

Mental health in Britain is in crisis.  The country has a long history of mental health crisis, of perpetual neglect.  PM Thatcher closed the large Victorian mental health hospitals in the 1980s without having set up her promised ‘care in the community’.  Their institutionalised residents, most of whom had known no other life than that of the long term hospital, were released onto the streets with no preparation, support or housing free to ‘enjoy’ their release into independent lives and many were soon intoxicated, left to street living, then dead or in prison – the definitive manifestation of Thatcher’s comment ‘There is no such thing as society….’as she set about destroying it and those who had been institutionalised.  This is crisis, and no marker of a civilised, humane, caring or concerned government.  Does the same comment apply to today’s situation?  Once more, we’re supposed to have or find ‘care in the community’, but mental health resources which were gradually built up after Thatcher, and particularly under the Labour (Blair) governments which followed, have been successively ruthlessly slashed during the Tory ‘austerity’ regime.  Starved of funding, depleted local authorities and much valued local, and regional supportive charities lacking minimal resources have closed, as have journals like ‘Mental Health Today’, ‘Open Mind’, ‘Health Equalities’.  Meetings between professional and lay people across the country supported by Trusts, Local Authorities, and NIMH have all gone; they  were more accessible sources of information, support and contacts for families suddenly embroiled in extreme situations for which they had no preparation.  The National Service Framework itself defining and ensuring statutory mental health standards across the country has gone along with the Local Implementation Teams (a mix of local lay and professional people) appointed to ensure those standards in mental health were met and reporting annually to their regional Strategic Health Authorities.  Meetings between lay and professional staff and the long established Community Health Councils – another local mix of professional and lay people overseeing all aspects of health, ImROC (Improving Recovery through Organisational Change), the NHS plan ‘New Ways of Working’ and the CLAHRC (Collaboration for Leadership in Applied Health Research and Care) initiatives have also come, promised well and then been destroyed.  Another scheme ‘Patient Voice’ had a brief life and now also seems to have disappeared.  Public Health itself has been savagely downgraded, and mental health is a public health issue.  Even the Health Service Journal covering all aspects of health, which was once available in main libraries enabling the public to see what is happening across the country, has become prohibitively expensive and so is no longer publicly available either.  Neither the right wing press nor the BBC have publicised any of these massive changes or the takeover of the NHS by US profiteering corporations.  Restoration of resources listed above would make an immense difference.  People need to know where and how they stand, what is available, what is best practice, what statutory standards to expect, and how they, as citizens, can challenge shortcomings, and come together both to demand restoration of unmet standards most effectively, and also contribute to their further good practice development in the light of practical life experience.  It is essential that access to reliable truthful information, with agreed standards is freely available, to know where to find it and to have a route to redress, thereby holding providers to account, and if all that fails, to be able to take complaints directly to a Minister.  Our concerns are about vulnerable people, children and elderly, most of whom cannot speak for themselves.  Without these facilities, is democracy just now limited to marking a cross on a ballot paper every 5 years?   

Health Inequalities in all aspects have significantly deteriorated in the 10+ years since Marmot’s initial Report.   A mental health system already fragmentary and inadequate to the needs of the population worsens as services are abandoned or left to profiteering private companies; they are likely to become even worse as ICSs begin to operate.  What happens when the capitation allocation is spent and patients of all types, including those with mental ill health needs have to manage as best they can alone with no service at all?  Currently mental ill-health in an estimated 25% of the population is grossly underfunded (10% was the last figure I saw in 2012).  I suspect the first figure is now greater, and the second less.

Now, added to that list, we have Covid, a pandemic which has seen the population trapped in their homes unable to meet, or demonstrate publicly, parliament itself effectively by-passed or closed down, a Prime Minister given to 5 o’clock presidential type pronouncements replacing parliamentary debate – giving him an unprecedented opportunity to push through further unexamined cuts and rationing, virtually unchallenged, more oppressive profiteering legislation, and ultimately ensuring permanent destruction of our inherited NHS.  We now have supposedly ‘post Covid’ austerity, although in reality, it is likely Covid will be with us for some years – most pandemics last 4 – 5 years – and the chronic repercussions and costs of ‘long-Covid’ are only now beginning to become apparent.  I understand 6 /10 Covid deaths have been in the disabled population in Britain.  If the Health and Care Bill currently before parliament is passed, health provision will pass legally and irreversibly into the hands of profiteering American, or American style corporations and we will be back to a Tudor version of care – families (mainly women in practice) to look after their own for love, with minimal or no support at all, in which case, the unloved surplus uneconomic and expensive elderly and vulnerable will be left, condemned to die on the street, as they do in America.  Our health service will have become fully Americanised, geared to profiteering to benefit their directors and shareholders.  Mental health care will suffer especially, because it is ‘the soft target’ as only people directly affected and their families care about it in the main, and those suffering can be effectively stigmatised by the tabloid press as ‘lazy’, ‘workshy’, ‘loonies’ – unworthy of any state financial support.  

The NHS model is the world’s cheapest and most cost effective, equitable health care, cheaper than insurance for both government and the people.  The Health and Care Bill 2021 is based on the US model with US companies in charge; they already hold the purse strings in the ICSs.  In practice, the US badly needs an NHS to replace their broken system and we do not need or want their broken model prioritising private profit.  With the US model, health care is available if you can afford it, otherwise almost nothing.  The British right wing media including, disgracefully, the national news provider, the BBC, has ignored all the stealthy steps towards destruction of the NHS since the process began in the mid 1970s, salami slicing with successive cuts.  The NHS has been underfunded, understaffed, qualified replaced by less qualified staff (ideally volunteers).  ‘Apps’ and computerised scripts to be spoken by school leavers have replaced GP appointments.  These changes might work for simple conditions, but will not do for the more complex problems of the older and vulnerable.  Furthermore, clinical signs unrecognised by the patient but apparent to the GP in a personal visit, will be missed.  The previous personal contact, relationship and confidentiality secure with the family doctor will have disappeared for those who most need it.  Psychological problems, domestic abuse and concerns are most often disclosed in the safe trusted confidentiality of the GP surgery; it is most unlikely to be revealed to an anonymous impersonal electronic computer ‘voice’.  Under-resourcing is real on all fronts, the move is towards a self diagnosis and self care scheme.  The distinction between private and public provision is likely to be further blurred as staff will be shifted between them, detached, de-unionised (of course), atomised flotsam on the infinitely ‘flexible’ ICS tide.  The current Health and Care Bill (2021) is the end game.  Added to that now, we have an impoverished ageing population, increased abuse in both domestic and wider society as bullying becomes endemic, widespread hunger, unemployment and the psychological damage of sudden bereavement and ‘long Covid’ symptoms, homelessness, total insecurity in a globalised world of zero hours instability, total imminent impermanence, even the prospect of no future at all with impending climate disasters during this increasingly authoritarian repressive refugee century.  The links between these high stress adversities and uncertainties with mental and physical ill health are undeniable.  Predictably, the demand for mental health care at all ages is grossly unmet, and likely to continue increasing apace.  Britain, for the moment, and possibly the foreseeable future, has become Theresa May’s ‘hostile environment’, not just for all the generous humane foreigners and friends, alongside the dedicated British men and women who once staffed the health, care and other services, but for its own subject citizens. 

The ‘medical model’ does not lend itself to resolving problems associated with shifting feelings, thoughts, difficult life experiences, trauma, relationships, meanings, abuse, frustrations, even lack of care , love or early attachment (real or perceived).  Any resulting ‘symptoms of distress’ cannot generally be linked to diagnosable disease problems of specific body organs, including the brain, nor to a few genes.  So they do not lead to reliable ‘diagnosis’, aetiology, treatment or prognosis, though symptoms can usually be suppressed / relieved and patients sedated with antidepressant or antipsychotic medications.  These drugs are sometimes invaluable at times of high stress to ‘cap’ a crisis as originally defined by the Stress Vulnerability Model.   However, socio-economic deprivation, inequalities (gender, age, religious, racism, cultural, wealth, isolation), alienation, bullying, ‘social media’ and other exploitation, domestic and street violence, homelessness, loneliness, lack of opportunities, blacklisting, being ‘cancelled’ etc… all have inevitable consequences on mental health and do not lend themselves to ready physical medical diagnostic labels.  If these needs and provisions are to be addressed, a radically different approach to services, beyond the traditional medical model, is needed, providing varied choices for and with service users, their representative organisations and families.  Meanings, understanding, hope and some stability are central to emerging from mental distress, when adversity may potentially change, leading to personal development and growth commensurate with social justice.  The best resourced and most successful rehabilitation is found in special hospitals like Ashworth, Rampton and Broadmoor which are properly resourced.  Some psychiatrists have chosen to leave practice in the general community to work in special hospitals precisely because they can do the job properly resourced.  

Some suggestions.  These all require universal standards and resources.  The cuts of the last decade undermining the NHS have been devastating and need to be reversed.  Health has to be recognised as an investment since a weak, sick workforce cannot work well.  Without proper standards, resources, capacity and staff numbers, including the active inclusion and participation of progressively minded professional bodies and staff liaising with recipients of services and their families in co-production of design, delivery and feedback as devised with ImROC (Implementing Recovery through Organisational Change), we will continue along the present pathway to further, deeper and worsening mental health crises; lives will continue to be blighted and lost.  Investments of time, people and finance to inform and educate service users, families and staff individually and in groups, showing how they can best work together, rather than in isolated silos and hierarchies, to achieve better results, better understanding, better resilience, recognise when friends /family members need extra support and of what sort, develop more experience and confidence to help themselves and others, would all lead to better outcomes.  It is crucial that people working at the grass roots are properly paid as professionals carrying huge responsibilities and are supported by informed, qualified and experienced senior managers committed to their vulnerable clients /patients rather than to personal career progression.  Equally crucially, case loads should be recognised and observed so staff are not overwhelmed, burned out, unable to cope personally with the daily tragedies confronting them, leave to take better paid jobs with no responsibilities and in consequence, training, professionalism are wasted and lives are lost.  Whistle-blowers must be respected and not penalised / bullied for speaking up.  We live in an unhealthy culture in which bullying, mental and physical assault is sadly endemic and ‘normalised’, sycophants are respected and rewarded and personal gain is the main (?only) consideration, whilst challenge is unwelcome, inequalities are increasing and increasingly ignored and lives continue to be lost.  I understand child mortality in Britain is the worst in Western developed countries and in England, 28 young children are killed /year.  How many manage somehow to survive persecution, attacks and starvation and other cruelties knowing no love at all?  What sort of adults and parents do they become eventually?  How often do we hear ‘lessons will be learned’, and know we will continue to hear those same platitudes when yet another ‘unacceptable’ atrocity has come to light?  

I am using the term ‘family’ for anyone who is intimately involved with the service user long term in a close social network equivalent to a family.

  1. The main staff member, more if possible, working with the service user should be able to offer continuity of support (say for about 2 years).  Continuity and consistency to develop a quality relationship, mutual trust and respect in therapy is always important, but even more so with mental distress than in conventional illness, because it is long rather than short term.  It is particularly important if there is a possibility of abuse in the service user’s childhood and that needs the most sensitive approach developing from a mutual trust built gradually over time – not easy
  1. Efforts should be made to provide a staff member of the same gender, and compatible background / ethnicity as the service user.  The disproportionate rate of admission and compulsory detention of people of ethnicity, especially black men in psychiatric wards and prisons needs to be seriously addressed.  The service user, highly stressed, in high alert, frightened, usually alone and in an alien environment, ignorant of the procedures to which he’s subjected and over which he has no control, and insecure of the culture and his legal position, is the most vulnerable person in an interview or dispute situation.  To have someone empathic, someone to whom they can relate culturally, can help, and this terrifying situation might then provide valuable learning opportunities for most staff who may not share or know any of the life circumstances of the service user.  Refugees, people traumatised by wars, floods, famine, shootings, prejudice, discrimination, attacks, threats, hunger, enslavement, being trafficked, subjected to years of abuse, people who may have lost everyone and everything they value, probably have experiences very different from the professionals in charge of their interview.  

3  The service user should have an early sensitive assessment to create a picture of their strengths and weaknesses,  vulnerabilities and personal circumstances; this will be modified with increased time, understanding and developments and should be co-produced.  The ‘Recovery Star’ approach worked very well for most people and gave agency and control to the service user.

4  The service user’s narrative and that of his relevant family is important, and may lead to 

(i) understanding of how the problem has arisen, 

and (ii)      how the family can best support the service user, + how their understanding and support might be further enhanced.    

5  If mental health issues are detected early, it’s more likely recovery will be easier, more complete and possibly faster, and the service user will be more likely to pick up their original contacts and life and social threads successfully, whether at school, higher education or work.  So, Early Interventions are best at all ages.  Early symptoms of mental distress often first appear in childhood and adolescence, so teachers should have some awareness training in recognition of potential problems and be able to access prompt professional specialised support.  ‘Interventions’ is an unfortunate title in some ways as it implies services ‘taking over’ rather than being an additional help – ‘On top rather than on tap’.  Crisis services must be maintained and available and be readily accessible.  It must never be forgotten that families (usually one individual in practice) are alone in a crisis; there is no emergency button to summon immediate help in domestic situations, and some carers end up dead.

6   The family will usually need, welcome and benefit from psychological support, and that may become apparent when they are interviewed.  All informal natural supporters are an invaluable free resource to professionals and need to be included as effective partners.  Most families can benefit enormously from psychosocial education sessions to better understand the situation of their service user, and provision of relevant short (day long) courses, particularly alongside professionals, also facilitate improved understanding between families and professionals and entails families meeting other families in similar situations thereby generating more informal networks – cooperative supports in everyone’s interest – and ultimately establishing supportive family groups which may become self sufficient.  Good informed family support can be crucial and is proven to produce better outcomes, so the family should not be designated ‘dysfunctional’ by the professionals; it is not helpful.  Instead, the family’s profound distress, acknowledging it’s making its best efforts to manage difficulties for which it has had no preparation and in need of some support to supplement its own inherent wisdom and love should be recognised.  Academic courses in universities which include specific sessions by the lived experience of family carers are always much valued by students, and should be more widely introduced.

7   Professional staff need a training in the various psychological techniques available, learning to LISTEN actively, and be trained in non-stigmatising language and behaviour.  All members of staff need to be confident that they can work effectively and reflectively in this way.  This means using understandable ordinary, rather than pathologising, language where possible, avoiding acronyms and technical terms and truly respecting everyone’s contribution in a non-hierarchical manner.  Talking about feelings – ‘I’ statements rather than ‘You’ are an important start to owning and managing difficulties between conflicts and cultures.

8   Relapse prevention techniques, how best to keep well, the early warning signs specific to the individual, and effective interventions should be explained and discussed with the service user and their supporters in a way in which everyone is an equal contributor (Triangle of Care style),  This should be based on the individual’s needs rather than service based.  To have a trusted informed person who can be contacted for support by the service user or their family, if necessary, helps enormously.  The need to move away from perpetual crisis or its threat is essential

9   Access to psychological therapies should be available long term (maybe about 5 years) if necessary, with review at intervals.  An arbitrary mechanised style time restricted system does not work

 10  Medication is used extensively as an easy and rapid way of suppressing difficult symptoms and all have a sedative effect blunting emotional reactions.  Medications are a lifeline to some, and some people choose actively to continue using them, but they offer no cure and cannot do so.  They have serious adverse effects on physiological functioning, often reduce intellectual functioning and may reduce life span.  Meds used sparingly for the short term to cap a crisis is undoubted and the Stress Vulnerability Model must always be borne in mind especially with people who experience psychosis.  However, there is more doubt about relying on medication as a long term solution, so serious discussion with wide participation is needed about their continued use long term.  Facilities to support those wishing to wean themselves off medication dependency should be available but are not officially supported in this country as yet.  The ‘do it yourself’ system tried by an individual almost always fails as tapering the dose especially near the minimal effective clinical dose is crucial and may precipitate crisis without proper support.

11   Risk management must be transparent and robust, but like anyone else, people designated mentally ill must be allowed to make unwise decisions      

12  ElectroConvulsive Treatment (ECT) Suites are still built and widely used.  Most service users report long term / permanent damage to their brain function after treatment, others report short term advantages.  Its complete discontinuation should be seriously discussed, again with a wide participation of people with real life experience

13  Community Treatment Orders (CTOs) were much more prescribed than had ever been anticipated.  If someone can be relied on to attend a clinic regularly, they should not be on a CTO.  A practitioner visiting the service user in their own home is able to assess how well they are coping overall and the service user in his own home is more likely to feel relaxed to discuss difficulties.  

14   To have good mental health, adequate income, friends, a safe, warm home, to be valued as an individual, occupied in a way personally acceptable and supportive, and with access to creative arts are needed.  Oppression in any of its forms at individual, institutional or structural levels should be outlawed.

15   All support services should be accountable to the public and truly ‘person-centred’.  This is a major problem with the unaccountable ‘Integrated Care Systems’.  They are accountable to their directors and shareholders not the patients or their families, arguably part of a modern asset stripping colonisation. 

16  The neo-liberal model inevitably generates mental ill-health with its dominating ‘winner takes all’ attitude, and with the majority population labelled ‘losers’, and consequently irrelevant, of no importance, ‘disposable’ people ripe only for exploitation or disposal.  It is an uncaring, impersonal machine and is causing ever more distress.  A healthy thriving society develops when humane principles and values are core, social justice and the natural supports of collaborative friendship are recognised.  Without those attributes, we have atomised individuals, and a society which is not thriving, not healthy, its people exhibiting rising fears, chronic isolation, self harm, suicides, frustrations promoting unpredictable anger with violence and bullying in response and mental health crises rocketing as an inevitable consequence.  The current neo-liberal model is anti-democratic, it supports and incites, maybe requires, unsociability, ruthless bullying and aggression, domineering and possibly promoting  psychopathic acts of violence in adherents.  A recent academic publication has resurrected the term ‘social murder’, a term coined by Engels after he saw the grim lives of the cotton workers of Manchester in the 1840s.  Everyone is forced into being competitors; liaisons of the gaming type occur, but as temporary measures after consideration about whether there’s more to be gained personally than lost in any exchange.  So friendship, family, neighbours and colleagues, all and every relationship, no matter how ‘natural’, long standing and important, can be severed, sacrificed to Mammon and personal gain.  This is not a civilised society.

17  Self help groups like ‘Hearing Voices’, NSUN (National Service Users Network) and DPAK (Disabled People Against Cuts), SWAN (Social Work Action Network)  are present and are extremely helpful where they’re applicable and if there are local branches.  Service users and carer families can share experiences, sometimes find their best supports, maturing into lifelong friendships, with those who have suffered similar experiences.  They need to be encouraged and supported; they reduce stress and increase resilience, they are intrinsic to people thinking constructively about building their lives and maybe thinking about necessary reform of systems which may not have been helpful, might even have undermined and discouraged people from collaborating and sharing progressive ideas.  

18  Alternative ways of helping those with mental illness in which the service user is key, need better exploration.  Some  are ‘retreats’, some religiously based but not all, providing a short relief stay of a few days, some are Crisis Houses, some are rehabilitation centres, some are residential and others are for day attendance and others offer different approaches to making progress  Examples include: Dial House Leeds, Soteria Houses, Lothlorien, Open Dialogue, residential and day farm communities, allotment /garden communities, some are specifically for children and young people, others for adults.  More of these are needed    

19  Advance Statements are recommended.  Service users likely to be hospitalised are encouraged to list their preferences for treatment, and those which have not worked for them, who is to manage their different responsibilities for family, domestic and pets when they’re indisposed.  It’s like a low key short term informal Legal Power of Attorney and should be given to the clinician and whoever is listed in their support team, kept on the top of their notes and respected.  It’s a document made, like the LPA, when the individual is in good health and doesn’t require official registration (unlike the LPA)        

20   Prison populations    It’s reported that over 70% of men in prison have a mental health ‘diagnosis’ and are on prescribed medications (usually anti-psychotics).  Prison is inappropriate for them.   Women are often in prison for offences like petty theft, being drug ‘mules’, or failing to pay their Community Charges as they’ve chosen to feed their children instead, and although these sentences are often very short (less than 6 months), they may lose their children permanently; these are distressed vulnerable mothers.  Prison is inappropriate for them too.  Some women who have been admitted to the psychiatric ward also lose their children. Whenever children are lost to children’s homes or fostering/adoption services for whatever reason, they may never be recovered again, causing permanent damage to everyone affected.  This is unacceptable.  There are too many vulnerable ‘looked after children’ who may be open to abuse and exploitation.  Sometimes, such children are freely and lightly passed from one ‘foster’ family to another as the care fees they represent helps relieve the poverty in which so many people are now permanently immersed, and the insecurities and likelihood of those children being exposed to additional exploitation are increased.  

21  Mindfulness has become popular in recent years and is very useful for some people.  However, it pushes the problem back to the individuals making them responsible for their own situation and removed from the socio-psycho- economic situation in which they find themselves trapped and over which they have neither control, nor agents in its reform.   Mindfulness has its place but it is no solution to current societal ills and problems which are likely to worsen in coming years.

22   A cross party small group of people, MPs and elected representatives of the diverse groups of disabled citizens should lobby for the concerns of the disabled and have direct access to a Minister; there has to be accountability.    A Minister for the Disabled, and a named MP responsible for mental health should be appointed

23  Telephone helplines, staffed by trained volunteers (with access to further professional back-up when necessary) in the style of Childline, Silverline, Rape Crisis and the Samaritans would be useful.  Suitably anonymised, collected and collated information would be a useful guide to major problems for prioritising

24  Proper consideration must be given to those who are multiply ‘disabled’  eg:  someone who is a mental health service user, deaf and caring for a physically disabled partner often told me there were no services for him.   Refugees may arrive variously traumatised by their experiences; they may still be children, of different ethnicity, cultural and religious backgrounds and with mental distress and /or with other health problems.   Raped pregnant Moslem girls aged 12 or 13 from Africa and the Middle East, rejected by their families have found sanctuary in Liverpool and had their babies supported entirely by local Liverpudlians 

25   Some attention must be given to mental ill health in people of other ethnicities.  Racial prejudice expressed quite openly currently against anyone with physically observable differences in skin colour or dress is rising, and rather encouraged by populist politicians and is not being effectively challenged; it’s shocking and unacceptable.  Mental health problems are often hidden in families, denied, stigmatised (including within the family) as ‘the evil eye’, resulting in individuals, even or especially children being ostracised, persecuted even killed as ‘witches’ bringing ‘bad spirits’ or bad fortune to the family (eg: Victoria Climbie).  Sometimes an innocent child bride, imported from a different culture and society as his mother was, is seen as causing mental ill health and is vividly described by Satnam Sanghera in his book ‘The boy with the top knot’ describing his childhood in Wolverhampton.  Locally in Liverpool, the Chinese community deny any knowledge of any mental ill health in their community.  I have known professional well educated Caribbean and West African families deny mental distress and even profound autism in their child.  These are deep rooted issues, as is distrust of white former colonialists .  I do not know how these situations should be best addressed although the participation of trusted professional staff who also understand and can work with ethnic sensitivities, probably grew up in them, would seem essential.  

26   I do not know if we still have a Patients Charter, or if it has any teeth if it exists.  All Charters should be able to challenge bad practices and to be able to hold governments to account legally.  The founding principles of the NHS used to form the basis of the Patients Charter.  A government should have unequivocal duties to support the health and welfare of its population.  The state of greatly increasing health inequalities within this country confirm the government is not. This country has now become ‘the sick man of Europe’ as a result

27   As soon as they are diagnosed, people who suffer from Parkinson’s Disease or cancer are able to access specialised help and advice at all times by immediate phone contact person who comes to know their clients very well and who attends to the problem raised personally or refers it to an appropriate person that same day.  Within an hour or so, help is there and it is crosses disciplines – no silos.  Nothing like this exists for people with mental health conditions, but it should.

28   Symptoms of other health problems are too often ignored if a patient has a mental health ‘diagnosis’.  Even acute appendicitis has been ignored in the past.  This must not happen