As standards fall, so all state provided care has to be second rate..

NHSreality has reported on the falling standards across the 4 Health jurisdictions. ( There is no NHS, particularly in Wales, where it all began.) Matthew Paris is well aware of the health service problems and issues. His last two articles in the Times reveal the insight. Even Mr Parris, far advanced in his thinking, cannot conceive of a nation that rations health care overtly, even though every other country does! What hope for the politicians to change their mindset if Mr Parris wont?

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The NHS guarantees second‑rate healthcare 7th November 2018: Amid celebrations for its 70th anniversary, the health service continues to provide, at best, a middling public benefit

…The purpose of my column is to explain that this is not an unfortunate defect in the system but a necessary feature of British healthcare which, conceived as our NHS was, can never be remedied. If medical attention is free at the point of use there must always be queues, always waiting lists, and navigating the system must always be a bit of a struggle….

We could….Charge everyone. Raise prices until demand drops to meet supply. But in the case of health we may not give that answer in this country….. The fear of illness and death is inseparable from the human condition and beyond remedy. But the fear of sickness for which we cannot afford treatment, which still haunts the greater part of humanity, is a horrible thing and in Britain we’ve abolished it. I’m proud of that. Personally I’d favour charging those who can easily afford to pay, but this is politically so far beyond the reach of a Conservative government that it’s hardly worth discussing. And for those unable to afford healthcare we must always provide it.

24th November 2018: Pouring billions into treating mental illness doesn’t add up – Matthew Parris, whose family has been afflicted by depression and suicide, argues it’s wrong to spend so much on talking therapies and medication when there’s little evidence they work

There are subjects so sensitive that it becomes necessary to begin with a warning. I do not want to attract murmurs of support from the “Mental illness? Stuff-and-nonsense!” brigade. Concern about mental health is not a fuss about nothing and there is no denying either the problem of mental illness or its scale.

Mental imbalance, depression, demotivation, trauma, anger, suicide, paranoia and schizophrenia in all its forms eat away lives, wreck families, damage society, burden the police, cram the courts and disrupt the workplace…..

…My focus is … upon one word: “treatment”. Does it actually work? How well? When politicians wrap themselves in the flag of “increased spending on mental health”, what treatments are they actually talking about? Do we know how much they achieve? What do they cost?

I want to look at the forms this “treatment” for mental illness takes, but first the most fundamental question of all. Is psychiatry even a science, in the way medicine is?

Sciences are based on theory: an explanation of how things work and the “laws” according to which they behave. Newtonian physics forms the theoretical base for our understanding of the interactions between matter. It has reliable predictive power. If a billiard ball smashes into one end of a line of static billiard balls, the ball at the end will come loose and shoot forward with the same momentum as the first ball imparted. We can predict this. If we cannot predict on the basis of our theory, or if our predictions prove wrong, we question, abandon or refine the theory. We feel safe in an aeroplane because theories of aerodynamics have been tested for their predictive power.

Like British Airways, the NHS is based on science. Physical health — the drugs, therapies and surgery with which what we loosely call “medicine” treats bodily ailments — is a group of advanced sciences. William Harvey described and explained the circulatory system. Thomas Lister pioneered theories about infection and hygiene. J S Haldane established the ruling theory of respiration.

Within (of course) limits, doctors can predict what will happen if you swallow this pill, drink that medicine, receive this injection or have that bit cut out of you. We know what works, we know what it costs, we can estimate the chances of an effective cure, we can (approximately) measure improvements in a patient’s health, and we can do the cost-benefit analysis. Cost-benefit analysis should be the foundation of all efficient governance.

On such a definition of science, psychiatry’s claims to be a science are weak. For a start, there is no universally agreed ruling theory of the mind. Who are the Harveys, Haldanes or Listers of psychiatry? Freud, Adler, Jung, with their theories variously positing realms like the ego, super-ego and id, the “will to power”, the “collective unconscious”? People pay good money for sessions with psychoanalysts who base their disciplines on such claimed structures of the mind, but as a theoretical basis for the science of psychiatry, they find no general acceptance and appear incapable of being tested. Then you have electro-convulsive therapy (ECT) for which large claims are made by its disciples in the treatment of depression and “psychosis” but for which systematic evidence of success is thin.

I cite these (usually privately paid for) therapies only to indicate the confused state of theories of the mind. Government-sponsored mental health provision is generally more workaday. Cognitive behavioural therapy (CBT) is often favoured: a treatment which aims to change the way people with mental disorders respond, in thought and action, to the world. You could call it a glorified version of age-old adult guidance to errant children to look for the good in others, see the glass as half full, turn the other cheek, breathe deeply and count to ten, etc . . .

CBT on the NHS takes place in counselling sessions for which taxpayers pay. I’ve yet to see systematic evidence of its effectiveness. There’s a lamentable tendency among mental health professionals to measure success by asking patients but asking someone whether a mental health treatment is helping them proves little if unsupported by any other data. They’ll have made an effort with a treatment, feel warmly towards the counsellor who is trying to help, and gratified that a trained person is spending time with them, talking sympathetically, listening to their problems. Their answers to the question “Do you think this is helping?” are bound to be unreliable.

Systematic and large-scale testing would be necessary to prove the efficacy of CBT. For comparison with results for those receiving expert professional help, one would need two sets of “controls”: first, a set of patients receiving no treatment at all and left to fend for themselves; and, second, a set of patients receiving what they believed to be professional counselling, but which was in fact carried out by amateurs with people-skills but no theoretical psychiatric training. The kind of thing that a good vicar does.

The same is true more widely of the whole counselling business. I’ve been unable to establish what the British state spends on counselling. In various forms the police, the NHS, the armed forces, education authorities and social services (to name just a few) provide counselling; training to be a counsellor is becoming a popular career path for community-minded younger people.

After I’d reported seeing a dead body by the Thames, my flatmate and I were both offered counselling. After my suitcase was ransacked on a train I was offered counselling. I accept that my response (to shrug off the very idea) will not be typical of everyone, and perhaps this service does protect some people from serious psychological damage; but again I ask, what systematic inquiry has been made into outcomes, as between those who receive professional counselling, those who think they have, and those who receive none? The cost to the taxpayer of state-funded counselling services must be considerable. What therapeutic bang are we getting for our taxpayer buck?

This brings me to a very hazy area indeed. Prescription drugs, uppers, downers and the range of chemicals we now call opioids, “happy pills”, and Ritalin (the so-called “chemical cosh” for “hyperactive” children) ought, I suppose, to be included under the heading “spending on mental health”. Sleeping tablets? Codeine? Where do you stop?It’s not for me to pronounce on how effective these various and very different chemical compounds are at producing the changes to the brain and to behaviour that Big Pharma claims. We’ve all read of trials that suggest that in some cases placebos achieve strikingly similar results to the real thing; but that cannot be universally true. Chemicals, licit or illicit, can clearly be mind-altering substances.

What is not in doubt is that patient demand for these drugs has grown and is growing, and our era’s fashion for “medicalising” mental problems is growing with it. Overworked GPs may fall back on easy pills for mental ills and addiction may follow.

All this medication for what are mental rather than physical disorders may boost the total national expenditure on mental health which politicians like to boast about, but is it always a positive step? Years ago I visited a primary school in Tyneside where the head teacher told me that a quarter of her children were on Ritalin. Many will progress to other mind-altering prescription drugs later. According to the figures from the NHS Business Services Authority, one in six 18 to 64-year-olds were prescribed antidepressants at some point last year, rising to one in five among those aged 65 and over. The costs will be huge.

However, there’s nothing black and white about our grey matter. I question whether the direction we’re going in — of ever greater categorisation of mental disorder — is affordable or of proven worth. Of course, there are levels of autism that seriously interfere with a person’s ability to co-exist satisfactorily with others. Obsessive-compulsive disorder does sometimes amount to mental illness. Anxiety, untreated, can paralyse. Hyperactivity in a child may amount to a mental disorder. Grief and shock may be so severe that post-traumatic stress disorder becomes a real diagnosis. Low self-esteem, if low enough, can cripple. I know from the suicide of my own brother how an unbalanced mind can tip a person into horrors every bit as cruel as physical pain.

All this is true — but does the use of medicalese to describe what may simply be unusually striking instances of common human qualities and responses encourage us to reach too easily for a mental “disorder” to blame? The Times reported yesterday the results of a survey of more than 9,000 young people which suggests that one in four young women “has mental illness”. So the state is called in. And soon politicians are congratulating themselves for “recognising the scourge” of mental illness, and demanding an NHS “parity of esteem” between those sick in mind and those sick in body. And the cost mounts. And it’s unclear whether the benefits follow. Is anyone in government really thinking this through?

Airing mental illness has to be right. On and off throughout his life my late father suffered from what it’s now clear were spells of severe depression. You could actually see his skin change colour. Yet these dreadful troughs were never defined or talked about among us Parrises. We were just sad that Dad sometimes seemed so depressed and withdrawn; and it hurt my mother, a bright and loving soul, particularly.

I wish he had been able to talk about it, to explain. These days we would have invited him to, but if I am honest I cannot say this would have made Dad happier. His drug was nicotine, and anyone who thought my father would have benefited from “counselling” would not have known my father.

And if I am even more honest I would admit to just a trace of admiration for Dad’s silence. We talk now about the “stigma” of mental disorder as though this arises only from ignorance but it’s as old as man — Jesus cast out “demons” — and there’s a Darwinian reason for it. The presumption of sanity in another is vital for human association. If people are sometimes not “themselves” then this must always be slightly frightening in a way that physical impairment is not. No government programme, no “parity of esteem” will ever eradicate that response.

We should never be unkind. We should always be ready to listen and to comfort. We must not airily dismiss. And if drugs of proven efficacy can sometimes help, we should not rule these out. Beyond this, though, and until a proper science worthy of the name can point the way, we should be cautious about throwing too much money at too speculative a profession. In our understanding of the mind and treatment of the mind, we are still in the Dark Ages. Results, please, first.

•1 in 4 people in Britain will experience a mental health problem this year, according to the charity Mind

•18% of those who tried to contact services when experiencing a crisis said they did not get the help they needed

•7.3m people in England were prescribed antidepressants in 2017-18, 4.4 million of whom were also prescribed such drugs in both of the two previous years

•1 in 4 patients surveyed said they had not seen NHS mental health staff enough to meet their needs in the past year

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This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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