Have you heard the story about the Zen Master and the Little Boy?! …
- The boy’s father bought him a horse for his fourteenth birthday and everyone in the village said, “Isn’t that wonderful, the boy got a horse?” and the Zen Master said, “We’ll see.”
- A couple of years later the boy fell from his horse, badly breaking his leg and everyone in the village said, “How awful, he won’t be able to walk properly.” The Zen Master said, “We’ll see.”
- Then, a war broke out and all the young men had to go and fight, but this young man couldn’t because his leg was still messed up and everyone said, “How wonderful!” The Zen Master said, “We’ll see.”
Not everything that looks like progress necessarily is; and even where we do see overall benefits, we will still see unintended consequences. We’re seeing the amount of attention given to policing and mental health increasing. There was a Policing and Mental Health summit lead by a PCC several months ago, one more last week and I’m aware of a third later in the year. We’re seeing the introduction of schemes to “improve” things ranging from street triage schemes, custody liaison and diversion schemes (8am-4pm, Monday to Friday, obviously) as well as forces adopting “tougher” stances towards what they see as inappropriate mental health related demands. Many of these schemes are being welcome and undoubtedly there will be consequences to these changes and we’ll see.
Change will always bring about consequences: both intended and unintended —
- We saw the whole mental health system deinstitutionalised much of its inpatient care provision in the decades after the 1970s and it continues apace at the moment.
- Last week’s reaction by the department of health to the BBC / Community Care investigation which revealed that the inpatient mental health system is now essentially full, was to comment that more than 6,000 patients now receive treatment in their own homes.
- It didn’t really address the issue of whether there we now commission sufficient beds to match predicted levels of demand or how we manage the excess.
- Unintended consequence: incredible numbers of patient-miles being clocked up in order to access an inpatient bed.
We see other intended consequences. We have lost around 1,700 inpatient mental health since 2011 and then we learn that the NHS is concerned that the use of section 136 MHA by the police is rising. Well, we have been asking the police to “get better at mental health” for some while and we’ve seen forces posting people to full-time positions, implementing training and now very active in areas where they were traditionally reactive. And not all of that is getting it right, because all the cops working on it have three or four hours of mental health training and very little mental health law training. So … we’ll see.
We have deinsitutionalised our healthcare, only to find we now have to imprison more people with mental health problems than ever before, a good number of which are restricted hospital order patients who created a victim on their way to an incredibly expensive care regime in a medium or high secure hospital which costs three or four times as much as the mental health bed that was decommissioned and that they couldn’t access. Other versions of those unintended consequences involve stories of self-harm and suicide which are often far worse. So more community care sounds attractive, but … we’ll see.
So we could tell the Zen story again: decisions being taken which appear to have superficially attractive consequences. Who can reasonably disagree with the proposition to deinstitutionalise for those who don’t need inpatient care and who could lead very worthwhile lives with community based mental health care? As Winnie the Pooh would say, this is “A GOOD THING!” We’ll see.
But then we hear stories of some of those patients being unable to access community care or being criminalised in order to access it, through section 136 in the cells or because they did something whilst in crisis and found themselves arrested for a public order or other minor offence. Some vulnerable people in these circumstances take their own lives and some end up in prison. We could all agree that this really is awful, but we’ll see.
DEMAND IS LIKE ENERGY
We all remember from physics that energy doesn’t just disappear, it goes somewhere. Intended or unintended: it is going to have to go somewhere. I very much see mental health related demand in these terms. If someone perceives themself to be at risk or in need of support that they don’t think they’re getting when they need it, only one of a few things is going to happen to that “need” —
- A person will seek informal supports from personal networks if they have them;
- A person will seek support from 999 or emergency health services like A&E / CrisisTeams / Out-of-Hours GP services.
- A person will fail to cope for themselves and take whatever instinctive or intuitive action they feel they have to – not always with positive outcomes.
An idea that I’ve been mulling over for some months however, is about the reaction of a predominantly medical model trying to “fix” people. I’ve read with interest many books over the last few years that people have recommended about the benefits / problems of a medical / bio-psycho-social model of mental distress. It’s all interesting stuff but I sometimes wonder if we’re over complicating it?
Sometimes people just want help — that can take many forms. In this week alone, in response recent blogs I’ve heard how some caring compassionate time on the part of two cops was just enough help and just the right time to prevent someone from taking their own life. Not treatment, just time spent trying to understand and support someone. It made me think of the WHO studies which suggested that recovery rates from mental distress in some developing countries without advanced healthcare systems is often better than recovery rates in the UK, Canada or Australia. In response to the same blogs, I’ve heard stories that people felt unsupported by attempts to diagnose them and medicate their problems away. These remarks are just to say something imprecise about the potential for human beings to help other human beings by not taxonomising their distress into inherently artificial categories like “personality disorder” or “substance abuse” or “functional mental illness”.
A health consultant recently said on Twitter that the problem with our (mental) health system is that it is a “Fix Me” system for “Help Me” patients. Therein seems to lie certain problems with our various efforts to change how we do what we do, both within the mental health system and with the broader public services that they sit within. And we can be certain that there will be some unpredicted and unintended consequences.
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