Conversations about the NHS
To mark the NHS turning 75 this year, leading psychiatrist Dinesh Bhugra wrote a book 'Conversations about the NHS' which reflects on the successes and challenges of the NHS.
In the interview below, he shines a light on the evolution of mental healthcare, homosexuality and mental illness, and equity of resources for both mental and physical health systems.
What was the motivation behind writing this book?
As the NHS was reaching its 75th anniversary I was keen to look at what is going on. In the 40+ years that I have worked in the NHS in one form or another, daily coverage in newspapers and the media has been either that it is in a crisis and/or some new expensive treatments for common or rare conditions which are not available on the NHS.
The demand is increasing, patient expectations are changing but the resources are not and politicians are tinkering with so called reforms every 18-24 months. The staff are tired and burnt out, with numbers of people leaving at an astonishing rate. The younger generation has very different attitudes to work-life balance, with a number of societal changes. With all these changes in mind, people take things for granted that NHS will look after them from cradle to grave but no one talks about how funding should be allocated and how patients and their families are involved in self-care.
For many years I have been suggesting that politicians need to be upfront about the costs and show a pie chart to demonstrate where every pound of money is going. I felt that it is a good time to look back and learn lessons. Maybe there was no golden age but the challenge remains: if we were setting it up today, will we do it the same way? So I decided to explore what key stakeholders’ views are and how we take the agenda forward. The royalties from the book are being donated to Patients Association.
Why did you decide on these particular contributors?
I wanted to include a range of stakeholders. Everyone interviewed has been or is actively involved in the NHS. From members of the House of Lords to trainees who have been past chairs of Junior Doctors committee and the past Chair of the Council of the BMA, past Presidents of Royal College of Physicians London and Royal College of General Practitioners, representatives from Patients Association, editor of The Lancet, two trainee psychiatrists-one is also a journalist for the Daily Mail and other is a Conservative MP thus giving a broad range of opinions.
What positive differences can we expect to see if mental health and physical health are seen as one/merged as was a theme in the book?
As we know patients with chronic physical morbidities are likely to develop co-morbid psychiatric conditions and patients with psychiatric conditions develop physical conditions which contribute to reduced longevity. Patients with psychiatric disorders often have disparities in longevity due to developing a co-existing physical condition which makes them die younger, with a noted difference of 15-20 years. Two services coming closer together should make pathways to care and navigation of services for patients and care-partners easier. It will also help reduce stigma and discrimination against people with psychiatric disorders, mental health professionals and carers. However, a simple merger is likely to have problems in terms of resource allocation to psychiatric disorders as more monies may get allocated to acute care. Equity of resources will be essential under these circumstances. This needs careful thought. There are models from around the world that the NHS can look at.
How are people who have mental health problems better off today than they were at the inception of the NHS?
There is no doubt that there has been tremendous progress in treating and managing mental illnesses. We now have a range of new physical and psychological therapies. Asylums have all gone. Services moved from institutions to community settings to home based treatments. In addition, crisis resolution teams and continuing care teams have emerged. Specialist services in very many areas have been developed and are working successfully although chronic under-funding remains an issue. We are more aware of geo-political and social determinants. In addition, services which are home focused are likely to need more human and financial resources so equitable proper funding is a must.
Do we still need a radical rethink of mental illness? And what does this mean?
Mental illness is not a single entity. Each individual’s experience of what they are feeling is very individual and strongly influenced by cultures, socio-economic status and other factors. Clinicians need to understand the illness perspective faced by their patients. Focus needs to be on social functioning even if symptoms continue to be present. In some cases symptom elimination may well be a problem. Clinical experience shows that many patients can continue to manage their symptoms well provided they have a certain level of functioning including employment, finances, homes, friendships and so on. We need to focus on bio-psycho-socio-spiritual-anthropological models. That means that training of all mental health professionals needs to be common for a period and broad. There has been an increasing danger in pathologizing normal human emotions and we must be aware of that.
Do you still think mental illness is at the bottom of the pile - with heart disease and stroke being at the top? Has anything changed in the past decade?
There are major challenges here. As far as funding is concerned there is no doubt that mental health services are extremely poorly funded. The Covid pandemic has shown what physical diseases can do to mental wellbeing. A major shift in the last decade has been that more people including celebrities, athletes, politicians are talking about mental illnesses which is really excellent. However, the challenge is to meet the needs of people who are experiencing mental illnesses. Equity in funding in mental health research and services is absolutely vital.
What is your opinion about the impact of the Covid pandemic on mental health - in both adults and children?
The pandemic showed how ill prepared the country was - not only in managing infectious illnesses but also the mental health consequences thereof. The separation of public health including public mental health and mental health and physical health raised several issues which were not identified. Higher rates of mortality in frontline staff who were often from ethnic minorities showed disparities at various levels. The lessons from previous epidemics e.g. Ebola, SARS-1, MERS and others have shown continuing problems, survivor guilt, poor physical conditions leading to mental distress have all been problematic and this again reflects separation between physical and mental health.
Prolonged grief and bereavement following deaths of loved ones when people were not allowed to come together to share their grief and perform rituals as culturally needed, has contributed to further alienation. Although the country came together as a family would in times of crisis, they were left feeling let down by so-called leaders - further adding to isolation. This has been difficult for children for who qualities of relationships with their teachers and friendships changed. How it has affected their brain and cognitive development, time will tell. Furthermore, for children and adolescents, already stretched CAMHS services are under an increasing amount of demand and consequent pressures. Services need to think outside the box to work with schools, communities, community organisations to provide assessments and advice.
Those who were working in the NHS and were clapped for five minutes or so every Thursday evening felt alienated when more pressures were put on them without appropriate resources.
Do you still feel strongly that more focus needs to be made on the mental wellbeing of gay people?
There is considerable research evidence to show that minority stress plays a major role in mental health and wellbeing of minority groups-be they ethnic or racial minorities, sexual minorities or with disabilities. These factors lead to higher rates of various psychiatric disorders and poorer outcomes. Among LGBT populations research has shown higher rates of suicidal ideation, suicide, anxiety, depression, alcohol and drug abuse when compared with rates in heterosexual majorities. Same-sex behaviours are still illegal in 70 countries and can lead to imprisonment, thus creating a second-class citizenry who feel threatened (if not overtly then most certainly covertly) in their daily lives. Interestingly it has been shown clearly that once equity is guaranteed in law, rates of these disorders start to fall. Evidence from the USA has shown that states which allow same-sex marriage show lower rates of psychiatric disorders in LGBT populations.
What do you see as the strengths of the NHS and how can we apply those strengths to improve mental health provision and understanding?
Basic principle of free healthcare at the point of need is a major strength. This takes away the fear of bankruptcy which is faced by individuals from lower socio-economic strata in the USA which spends almost double the amount on healthcare. The NHS allows economy of function and costs because services are commissioned at a large scale.
Mental health and physical health, primary and secondary care and health and social care need to come together as a matter of urgency. Health including mental health should not be seen in isolation as if it were in a silo. Health is inter-connected with education, employment, housing, justice etc. They all must come together and mental health has to be seen as a crucial part of all this.
What is your most memorable/significant time during all your years working in psychiatry?
On several occasions getting racial abuse from patients and discriminatory comments from colleagues from whom I should have expected better. However, many positive occasions too. At a social event a lady came up to me and asked me if I remembered her. I did not. She told me that she was my patient 19 years previously and she still remembered how helpful I had been and how she remembered what I had said to her. That was incredibly moving.