As mentioned above, problems with mental health services were unprompted in the interview but mentioned by all of the respondents. It should be noted here that some respondents also remarked on the successes of certain local services for example a local register of people with learning disabilities, the drug misuse service run by a voluntary organisation on behalf of the NHS and new training on the recovery model for mental health demonstrating that despite problems, their perspective on services was not entirely negative. Polarised views were picked up within the group on a number of issues including seeing the same services from very different angles. For example, one respondent emphasised a lack of attention on services for patients with severe and enduring mental health problems while another believed that the system coped well with these:
“P 19: The Board does not prioritise mental health issues.
PC: Who would you say suffers most from mental health services not being prioritized?
P 19: Oh people who, people with severe mental illnesses will be hurt most, people who won’t complain. GPs tend to respond to complaints, but certain patients, for example psychotic patients are unlikely to be able to complain and demand a service.” P19
“We do look at mental illness and we do have a fairly good robust
treatment programme and the GPs do recognise and identify and treat and they link into the CMHTs and it all seems to gel together and particularly if we are looking at the very severe end, the severe and enduring stuff, then that does seem to be coped with quite well.” P26
Other issues highlighted as being problematic are described below under the headings of: criticism of services and providers, gaps in services, overwhelmed services, lack of development, and limitations of services available.
Criticism of services and providers: Three aspects of mental health services drew
criticism from respondents. These could be described as direct service provision, data collection and use of information, and strategic leadership.
(i) Direct service provision: GPs were criticised for appearing to see mental
health patients as difficult and time consuming and primary care staff in general were thought by others to lack confidence in dealing with mental health problems. One respondent had been unable to get GPs on board for a suicide review process. The fact that mental health was not covered adequately by the Quality and Outcomes Framework was one reason suggested for difficulties encountered in involving GPs in mental health services.
One respondent believed that mental health can be used as a political football with involvement of drug companies:
“In some practices mental health is used as political football, […] and there is a problem with the training in primary care in that for mental health it is generally drug sponsored which means that sometimes guidelines are not enacted on, for example, for depression etc. Drug companies pay for speakers, but the NHS pays for GPs to attend, em, that kind of training and there doesn’t appear to be much appetite in the NHS for changing that, although in the CHP some senior CHP members are quite keen to change it.” P19
(ii) Data collection and use of information: Concerns were raised by one
respondent about data on mental health, such as hospital admission figures not being collected accurately and other data being collected but not used. Consequently the respondent believed that information could not be used to support changes in services and in addition, there were plans being produced that were proposing actions with no clear evidence base:
“there is a lack of epidemiology in there, but there are actions being identified as, you know, the right ones to take, but on what basis they’re being put forward is unclear so perhaps the route of the planning is deficient to some extent.” P26
(iii) Strategic level: A number of respondents expressed concern about lack of
leadership for mental health and well-being at all levels Board-wide and within the CHP. For example, there was said to be a lack of clarity about service provision for patients, with a multitude of possible entry points into mental health services. This was difficult for planners who were not involved in frontline services to understand, and prevented services being joined up at strategic level. There was concern expressed that organisational structures were focused on financial priorities rather than on clinical governance, and that entrenched professional boundaries were hindering integrated care management.
Gaps in services: Most respondents identified that there were major gaps in
psychological services and services for children and adolescents, both of which had also been highlighted in the mental health needs assessment:
“We are definitely short of psychological services of all sorts and the waiting list for psychology is just totally unrealistic. People do not have problems 18 months from now they have problems now. I’m sure that would be of great benefit, and child and adolescent services are virtually non-existent.” P5
Other services highlighted as having gaps were Cognitive Behavioural Therapy and addictions. The addiction substitution service which had been developed alongside primary care was praised by one respondent. However, problems were mentioned relating to addiction services in general, including that addiction reduction services were needed but unavailable. In addition, dual diagnosis with mental health often led to referral into addiction services, which was not always appropriate.
Overwhelmed services: Secondary and tertiary mental health services were said by
some respondents to be overwhelmed by patients who might be more appropriately dealt with at primary care level. This was said to have resulted in community psychiatric nurses doing less work with people with mild to moderate problems, such as relaxation and counselling, because of the high level of severe mental illness that they had to deal with. In addition, some community mental health teams were thought to be understaffed, adding to the pressure within the mental health system. One respondent was concerned that patients with mental health problems needed to be referred to someone who can
spend time with them, but this was often not an option as waiting lists for psychologists were too long.
Lack of development: Two respondents were concerned that the NHS Board had not
prioritised mental health in recent years. For example, a five year plan for mental health services produced in 1999 was only funded for one year, and the report from a mental health service re-design from four years ago had only been made available recently. Another respondent believed that mental health care and treatment has taken precedence over developmental work:
“We had a big focus on the mental health care and treatment not surprisingly, but that did stop us progressing the other agendas because everybody’s energy had to go onto that and that really meant that we were at a stand still for the development work, you know.” P26
Limitations of services available: Some respondents believed that there was a lack of
opportunity or resources to carry out preventive action for mental health, such as communicating information about health promotion or access to services to people with sensory impairment, or offering stress management sessions. One respondent was direct in his criticism of current health promotion efforts:
“Oh we’re not good at that. [prevention] Somebody going in with a quasi uniform or this view, I’m telling you what you should be doing – you shouldn’t be eating that fried mars bar. So what, get stuffed I’ll eat that if I want that’s all I can afford, rather than going in and saying, well okay you’re having that, but we could get you something much better for you and having that sort of approach.” P27
There was a feeling among some respondents that the current services were unable to meet the needs of patients with complex needs for example,
“in a simple uncomplicated depression that [recovery] is something that you can see, whereas it is much more difficult when there are 1001 problems to solve as well of the socio/relationship type.” P5
Two other respondents highlighted difficulties for current services for meeting complex needs including when a patient had a mental illness as well as physical problems such as Hepatitis B or Hepatitis C. One respondent was concerned that areas of deprivation did not get the best treatment for mental health, as people with chronic problems often didn’t seek help. Another respondent was also concerned that complex issues around a
mental illness posed a problem for the CHP and its partner agencies, as well as for individual practitioners:
“Again criminal justice, there is an overlap there of people that are offending who’s problems are very multifaceted, you know, so you’ve got addiction problems, mental health issues, poverty issues, offending issues, and it’s all very, very complex, you know, unpicking that and it’s just, in terms of how the CHP responds to mental health issues then it’s how broad do you make it and in some ways you have to kind of narrow, narrow down the, you know, the range really, so that in fact we’re not, we cant deal with everybody. In some ways I think that has been the difficulty in trying to work out exactly what the definition of mental health issues are.” P25
In summary, a picture emerged of an apparent lack of strategic leadership for mental health services. A complex system existed between mental health services and primary care with little clarity as to which problems should be dealt with by whom. Both primary care and mental health services appeared to be unhappy with the other’s efforts, and polarised and disparate views were expressed for many important issues in delivery of mental health services to very vulnerable patients. Services for people with mental health problems appeared to be under-funded and unable to deal with patients with dual diagnosis or complex circumstances, or to be able to take preventive action.