Imagine that a family member becomes critically unwell. You anxiously accompany them to A&E and the opinion of the doctor is clear – an emergency hospital admission is needed to avoid potentially devastating consequences. But unfortunately, says the doctor, the hospital happens to be full. And so are all the other local hospitals. So either your relative can take a trip to a private hospital in a town more than 200 miles away for their life-saving treatment, or you can take them home and have a go at nursing them yourself.
Surely if this ever happened, people would notice. But it does happen, every single day. It seems to be acceptable because the illnesses are psychiatric.
The profound suffering of people who attend A&E with psychiatric issues is almost impossible to underestimate. Be it the suicidal despair of depression, the terror of paranoia and hearing persecutory voices or the exhausting disinhibition of mania, mental illness is unconditionally deserving of the same level of comprehensive care as a physical ailment. But when somebody with a mental health problem needs to be admitted, doctors like me have to ring the bed manager and cross our fingers.
Too often my luck is out and I am forced to have a torturous conversation with a patient and their relatives about why they will need to sit in the back of an ambulance for four hours to get a resource as straightforward as a bed when they live 10 minutes from a psychiatric hospital. To go through this would be hard enough if you had a routine medical problem, but to our patients it feels like purgatory. They are at their most vulnerable and need care and attention, but what they actually get is exile. I had never felt ashamed to work for the NHS before I worked in these situations, but now a sense of pride is hard to come by.
A health select committee report published in August gave a clear indication that the lack of beds had become dangerous and that some doctors had started to section patients, who wouldn’t usually be regarded as unwell enough to fulfil the criteria, because that is the only way to force the provision of a bed. And an investigation by the BBC and Community Care magazine last week cast an even more detailed and human light upon the tragedy affecting those who need inpatient psychiatric care. Based on freedom of information requests, the bed occupancy of 28 mental health trusts in England and Wales was found to average 101%, far above the advised level of 85%, with some individual wards found to be running at an astonishing 138% capacity. The root of these startling and seemingly impossible figures is the practice of being forced to admit patients to a ward and into a bed belonging to a patient who is on a short trial period of home leave or, even worse, being forced to admit patients with no bed being available for them at all. It doesn’t take much effort to find someone who has had to sleep on a ward sofa – would this be acceptable for someone with a physical health problem?
The Victorian-style overcrowding sounds bad enough, but the alternative – being turned away – can be even more damaging. One patient, Lucy Bowden, reported how she wandered around the grounds of her emergency department until the police picked her up, locked her in their van and used an emergency section of the Mental Health Act to make finding a bed a legal necessity. Another, Mandy Peck, jumped to her death a day after being told that there were no beds available to ensure her safety. These instances are just the tip of a very disturbing and shaming iceberg.
The parity of esteem between physical and mental health endorsed this summer by this government reflects neither their decisions, nor how we react to them. When Jeremy Hunt drew the downgrading of Lewisham A&E out of his tombola of terrible decisions, there was uproar; televised marches and petitions signed thousand-fold. Yet between 2011 and 2012, we lost at least 1,711 psychiatric beds. That’s roughly 80 individual wards, or 9% of our beds. Astonishingly the closures continue, and our “ringfenced” budget has been cut for a second consecutive year. Yet hardly a whisper.
Reducing the number of psychiatric beds comes with a built-in spin mechanism: “we’re moving further towards care in the community”. What was long ago the laudable endeavour of a new psychiatry, chiming the death knell of the asylums, has since been hijacked as a mitigating tagline for a detrimental and bafflingly flawed reallocation in services. As part of “care in the community”, we somehow manage to pay private hospitals £25m a year by outsourcing psychiatric admissions because our own NHS beds are full – a rise of 32% in the last year alone.
As misguided and reprehensible as the practice of sectioning patients to get a bed may be, the very fact that doctors are endangering their careers to obtain a resource as basic as an admission to hospital should not be lost on those that criticise their professional conduct.
The select committee highlighted that community treatment orders (CTOs), introduced in England and Wales in 2007, appear to have done nothing to ease the pressure on beds. The Department of Health had estimated that 10% of patients on long-term inpatient sections would be diverted to CTOs, allowing them to continue their coercive treatment out of hospital. This was an interesting prediction, considering that a review funded by the DH noted that international research had consistently shown CTOs to be ineffective in preventing readmission to hospital. The number of sections has actually increased from 42,208 in 2008-09 to 44,894 by 2011-12, and a further large research trial of CTOs has all but confirmed their uselessness. CTOs grant psychiatrists just one power, in essence, to order a patient to return to hospital if they stop taking their medication or otherwise deteriorate. In practice this is barely easier than simply sectioning the patient again, so it is not hard to see why a growing band of detractors view CTOs as little more than a toothless appeasement to distract us from bed closures with more “care in the community”. Their administrative upkeep and paternalistic ethos create a futile sinkhole for time, money and, far more importantly, patient liberty.
Let’s be clear about this – psychiatric patients are among the most vulnerable that the NHS sees. They are a soft target for cuts. The very nature of mental illness makes it difficult for our patients to maintain supportive relationships and fight against the theft of the resources they need and deserve. To our discredit, we don’t support them enough to speak up or listen closely enough when they do.
I make no apologies for directly comparing standards of care in physical and mental health. If this were physical health, there would be outrage.
Dr Alex Langford is a junior psychiatrist at the South London and Maudsley NHS trust.
This article first appeared on The Guardian on 23 October, 2013.