In my last couple of posts I have been mainly talking about the different understanding society now has about the loss of mental wellbeing. I hope I have also demonstrated that we all share a responsibility for helping people who have in some way lost their mental wellbeing and are troubled
As I have said many times previously, it is not that we have all suddenly become mental health professionals, but we do have a a significant role to play. Yesterday I talked about some of the ways in which the public can make that contribution.
Turning to professional mental health services, there now seems a very strong belief across the NHS, politics, and society as a whole, that it is time to establish parity of service between mental and physical ill health. To get serious about this it is important to realise that this is not a matter of a few months of catching up but will take years. But we need a goal and a timetable.
The most significant step on the journey to gaining this parity of service will be getting the necessary staff. And if there is to be genuine parity a higher proportion of new NHS staff will be needed for mental health services.
But whatever the NHS may want (and a new compact with the public may well say that by 2023 we will need 50,000 extra nurses and 20,000 more doctors), it almost certainly won’t get them.
This is not just a Brexit problem (though it is), but a problem of international shortage. Currently the World Health Organisation argues that the world is short of 4.3 million trained doctors and nurses, By 2023 China and India will have at least doubled their currently low spend on their health services. It is a certainty that international demand for professional staff will increase as a result.
It’s a good thing that we in England will be training more professional staff, but it doesn’t follow that they will only want to work here. They may elect to spend time in other, more interesting, health services. Not to leave forever perhaps – but I can readily imagine that by 2020 a proportion of all our newly qualified staff could be interested in spending ten well paid tax-free years helping another country build its health service…
The point being that although for 70 years the international terms of trade in clinical labour markets has worked well for England, this will probably change. And this change will be happening at the very moment in history when mental health will need a lot more staff (to reach parity). That’s why parity of service is such a serious pledge to make. Because if we are going to take it seriously, it is going to divert professional staff currently working in physical health.
Two of the areas where mental health needs more staff are in A and E – as part of the primary health care team.
When I asked one CEO (with a very successful A and E department) which single reform had made the biggest positive difference to A and E operation, they were clear that it was having mental health nurses present 24/7. A and E departments are not pleasant places. They are an unhappy, highly concentrated, mixture of pain and distressed relatives. All with very high anxiety. Not a good place to have an episode of mental illness.
However, since A and E is also viewed as a place where you can expect some sort of service it makes sense for a person in mental health crisis to go there. But when you get there the high anxiety, emotionally-charged atmosphere is compounded by the absence of trained mental health professionals.
And, just as with physical ill health, the frontline mental health nurse in A and E needs access to a network of appropriate locations and treatment patterns to which patients can be referred. The crisis teams recently set up around the country are the start of this network – but only the start. Crises (and hopefully the resolution of crises) take place in every patient pathway, but there is just so much less of a solid pathway for people with mental health crises than others.
So I would argue that it is here – in the building of a set of solid and safe pathways for large or small crises – that we need to invest.
And just as the vast majority of physical health issues first arise at primary care, parity of service will mean that this will be the case for mental health as well. Think what this would mean within the primary care team – a considerable increase in mental health practice nurses and GPs with a special interest.
There is nothing unusual about any of the services that I have outlined here. The recognition that our society now gives to it requires that over the next five years mental health care needs to become normal – rather than special.
My purpose in drawing attention to this issue is to try and add some realism to the discussion about where the professional staff needed to bring about parity of service are going to come from. If I am right about the new international health landscape many of them are going to have to come from retrained professional staff who have had previous expertise in physical health.
For that to work we will need a lot more skill substitution throughout the whole NHS.