Psychiatry in the UK is in peril. Long waiting times, staff vacancies, recruitment and retention problems – we have known about this for years. But these problems, alongside inadequate inpatient provision (much of it outsourced at huge cost to substandard care in the private sector), are getting worse. Preventable homicides and suicides are becoming more frequent, too. Psychiatrists I have spoken to suggest that the June 2023 killing of three strangers by a psychiatric patient suffering from paranoid schizophrenia in Nottingham reflected a failure of basic care that has become shockingly commonplace.
Too much energy within mental health services is focused on keeping people out of the system: devising exclusion criteria to restrict access; limiting clinical engagement by restricting the length of sessions and duration of contact; and endlessly driving bed numbers down. These are simplistic “solutions” to a basic mathematical problem: the amount of need vastly outweighs what the service is equipped to provide. The effects – forcing patients to get worse before they can access the basic care they need – are perverse, and the system is both inefficient and inhumane.
And what does it do to psychiatrists themselves? Rejection and neglect have become part of everyday work, fostering an attitude of self-protectiveness in staff. Many struggle with the moral distress involved: the gulf between what is good professional practice – therapeutic interventions they know would be helpful – and what they can actually offer their severely distressed, high-risk patients. The burden for some is overwhelming; they fall ill themselves. Others resign. But there are some who are so used to letting people down in this callous system that they hardly notice the impact anymore.
When I became a consultant in the early 1990s, at the heart of the service were highly skilled, multi-disciplinary community-based teams, within easy reach of our patients and well-known to the local GPs. Relentless rounds of cost savings have meant that many such teams are now based in soulless office blocks miles away from where those who need them live. Waiting times are longer, bureaucratic demands have increased workloads, while time allocated for seeing patients is increasingly squeezed. Fragmented care is the norm, and the task psychiatrists are expected to address has become frustratingly narrow.
For example, if you decide your patient needs hospitalisation for their safety, the decision is passed on to another team. Admission is often refused by the hospital’s “bed bureau”. And at the end of their stay, most inpatients find themselves referred to a different consultant and team altogether. The pressure on outpatient psychiatrists is to diagnose and prescribe and get that done quickly – sometimes within half an hour. Yet we know that what many severely ill patients really need is a long-term therapeutic relationship. Psychiatrists are encouraged to ignore what was learned in training, and are increasingly put in impossible positions, no longer able to offer safe or dignified care.
Although psychiatrists are given responsibility, held to account and blamed when things go wrong, most would say they feel marginalised and lack the power to improve the system. This isn’t the case everywhere, but exemplary practice is rare, and even “good enough” practice is not widespread. Some of my most talented trainees, along with many others, have already left the profession, worn out with fighting a losing battle to maintain standards. The appointment of locums has escalated, in what has become a vicious circle of shortsightedness, mismanagement and denial. Many of these doctors are recruited from overseas; some work exclusively online, a small number never setting foot in the UK. Imagine struggling with severe mental health problems and, after nine months on a waiting list, receiving a Teams link; your long-awaited “help” consisting of no more than talking to an overseas psychiatrist with little knowledge of the NHS.
Some locums are well qualified – they choose the work because the money is better and the responsibility less. But there are many with questionable skills and incomplete training. Such a situation would certainly not be tolerated in surgery. Or elsewhere in medicine. It should not be in psychiatry.
Who is going to lead us out of this mess? The Royal College of Psychiatrists is supposed to support its members to practice to a professional standard. But in my nearly 40 years of membership, the college has never seemed so remote and out of touch with the day-to-day experience of psychiatrists or the patients they serve. True, it has worked hard to support its overseas membership, and has had a lot to say on topics such as racism and LGBT issues. It produces clinical guidelines and has help-lines that offer advice. But its tone sounds to me self-congratulatory and complacent, cautious and over-concerned with its reputation.
The college appears to have lost a sense of purpose. It is no longer confidently fulfilling its important role of giving a voice to psychiatry within medicine and the NHS, and for the wider public. The leadership seems unwilling to either address the situation most of its membership find themselves in, or grapple with the reality of pervasive substandard care. There is no willingness to draw attention to the neglect and brutality that some of our most disturbed and vulnerable patients are experiencing. There is a disconnect between the exacting academic (and extremely expensive) hoops psychiatrists are put through to become members and the reality of psychiatric practice through much of the UK.
A tangle of forces has taken hold and threatens to undermine our therapeutic connection with patients. The Royal College can’t change things on its own. But it needs to challenge the perverse incentives within the system that are eroding the essence of what it is to be a psychiatrist. If it doesn’t, I fear psychiatry is in danger of becoming a warped – and much diminished – version of itself.
Penelope Campling’s latest book is “On the Brink: Stories of Harm and Healing from a Lifetime in Psychiatry” (Elliott & Thompson)
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