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Thanks for the Memory

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A trip, last month,  to North Wales where I spent most of my childhood summer holidays and where, in turn, I had taken my own family, gave me the chance to indulge in some special memories. The experience made me pause to reflect on this most distinctive of human gifts and what it means for how we define ourselves and experience our lives.

I also enjoyed recently listening to some of Radio 3’s excellent series of programmes on music and memory. There were some fascinating insights onto how our memories work and some inspiring stories of how music can help in improving the quality of life of those affected by neurological conditions such as dementia or strokes.

I have been blessed (there are occasions when my family might say cursed) with a retentive memory, able to recall, without too much difficulty, facts and experiences. As a historian I am particularly good with dates and events, less good with plots and stories, which my wife is much better at. I am also good a retaining a sense of where I have been and while I often get lost on the way there, I rarely do on the way back.

I am also keen on things which help maintain memories. I’ve intermittently written a diary for much of my life, love taking photographs and keep notes on the more complicated things I read. I enjoy going back to those secondary sources from time to time, and like a cow with a second stomach, redigesting my memories.

However, my feats of memory are nothing compared to others. I am always amazed by how a musician like the pianist Andras Schiff can play from memory the whole of a piece as long and complicated as Book 1 of Bach’s Well Tempered Clavier. In previous ages powers of oral retention were inevitably greater than now. As a student I was fascinated to learn about the Yugoslav wedding singers of the early 20th Century who were capable of memorising a poem as long as the Iliad.

Memories can take different forms. For the most part my memories are visual but there are some which can be triggered by sounds, music, smells or just the recollection of feelings. I think about the experience of my older brother, who has been blind since birth, and who also has a good memory, and how his memories, sometimes of the same events as mine, must be cast in a very different currency.

Memories of course can also be a source of distress which cast a long and damaging shadow over future life. Forgetting and avoiding memories can be a natural way of dealing with painful and difficult experiences such as abuse. However, while consciously forgotten, painful memories can leave a deep and painful unconscious imprint on feelings and behaviour. The ability to process previous memories is central to being able to deal with the consequences in the present and lies at the heart of many psychotherapeutic disciplines.

Memories can be partial and it can be difficult sometimes to remember too much. The brain does an amazing job in filing and editing memories and using them to support different narratives in our lives. It is fascinating how, especially older people, can remember clearly the events of their childhood. I remember being staggered listening to my grandmother, at the end of her life, recalling with vivid lucidity, at a distance of ninety years Queen Victoria’s Diamond Jubilee when she would have struggled to remember what had happened earlier in the same day.

The loss of memory is a source of anxiety. The modest difficulties I now experience in being able to recall information, names or events (it always seems to come back just after I need it) bother me. There is no illness I fear more than dementia and it has been devastating to see its effects on family members and others. Listening to some of the programmes on Radio 3 reminded me of how little we still now about these conditions and, just as much, of the experience of those who are affected by them. The programmes also reminded me of the importance, not just of biological research and interventions but of the positive value of social and cultural responses, such as musical therapy and activities.

Memory is a crucial part of what defines us as individuals. This is also true for groups, societies and nations who often define themselves through shared memories including those second-hand memories which have been shared across generations. It is part of the complexity of making sense of the contemporary world to try to give proper respect, at a time of enormous change, to the bank of common memories which underpin intellectual and cultural identity without, at the same time, being locked in an unhealthy obsession with the past and without privileging one set of memories over another.

Good memories enrich life and experience and support good mental health. So indeed, thanks for the memory.

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Making things work for mental health

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The word landmark is overused but I think was appropriate for Paul Farmer and Dennis Stevenson’s report last week “Thriving at work” on the steps which need to be taken, to improve workplace mental health. It was a compelling call to action which highlighted the clear moral and economic case for improving mental health at work.  If implemented, it would not only address the immediate challenges implicit in 300,000 people with mental health problems leaving work each year it would also be symbolic of a fundamental shift in attitudes towards mental health in our society.

In the ten years or so I have worked in the field of mental health I have been aware of the importance work has in transforming perceptions of mental health.  It is already one of the areas where, in those ten years, significant change has taken place.  In 2007 you could count the organisations who took workplace mental health seriously on the figures of one hand.  There is now recognition of the issue, if not action, across the economy.  However, there is still a lot more to do.

My first exposure to mental health at work came before I joined the sector.  At a time of organisational change two of my team with historic, but at the time undisclosed, mental health problems became unwell and had extended periods of absence from work.  As their line manager it was a tremendously unsettling experience and on which I had no training on how to deal with.  Luckily, with positive help from HR, both returned to work and have continued successfully with their careers.  It could have been different.

In line with many of the recommendations in the Farmer/Stevenson review there are, in my view, a number of critical issues which need to be grasped if we are to create genuinely mental health friendly workplaces and realise the personal and economic benefits associated with that.

The first relates to mindset. By that I mean that organisations and their leaders genuinely value the contribution of employees who may have had or who may develop mental health problems.  It is a mindset that believes that, a history of mental health problems, does not devalue the skills and competences that those people bring to the job.  Indeed, that in some cases, the experience may add something additional in terms of commitment and insights.  As with physical health issues support and reasonable adjustments can be enacted which help people affected to continue to carry out their role.

The second covers organisational commitment to develop a strategy to support workplace mental health, to invest in the identified interventions and to monitor performance. As in other areas of change this agenda needs time round the board table if it is to be taken seriously and prioritised over other issues which can easily soak up management time.  An organisational strategy needs to be specific to the organisation and, while some generic interventions are appropriate, there needs to be analysis of the specifics of the organisational context.  The presentation of mental health stressors and the level of problems vary between organisations.  The four fold variation in the costs of mental health problems between different sectors was one of the fascinating facts from the Farmer/Stevenson report.

Above all strategies must mark long term commitment to this issue. At its heart this is a question of a cultural change, and as any of us in senior positions of management are aware, cultures don’t change without perseverance and sustained commitment over a period of time.  There is a strong message here for the NHS, amongst others, whose work on staff wellbeing and resilience has tended to be piecemeal and inconsistent.

The third focuses on the crucial role of line managers in supporting staff who have or may develop mental health problems. Their skills and competency in helping keep someone well or managing a situation when someone becomes unwell is often the biggest single factor in determining a successful outcome for an individual experiencing mental health problems.

Line manager training in mental health crucial but this must go beyond Mental Health First Aid, excellent starting point though that is. I would argue strongly that we need to build in a psychologically informed focus on wellbeing into a much range of management training, in particular in areas such as performance management and change management which are so often create potent stressors which can impact on the development of mental health problems.

Disclosure is an important factor in enabling line managers to carry out their role. As I know from my own experience situations are so much harder to deal with when the first conversation about mental health is when someone becomes unwell.  Organisations can help, in both formal and informal ways, to encourage employees to disclose issues but it is also easy to understand, given years of stigma and discrimination, why people don’t.   Initiatives such as BT’s mental health passport which allow a standard format for individuals to document, in discussion with their line manager, the nature of their issues, early warning signs of developing problems and the best strategies for supporting them are a very helpful way of normalising the issue.

My final point is that an agenda mental health at work cannot sit in isolation from a wider debate about the quality of working experience. While, on the whole, I accept the argument that work is good for one’s mental health, there are times when it is not.  A lack of work/life balance, constant and badly handled change, bullying and harassment, lack of value or appreciation of employee’s contributions, lack of autonomy in people’s roles are all casual factors for poor mental health.  As a Chief Executive I know all too well that it is impossible to shelter an organisation from all the pressures of the external environment but leaders can not absolve themselves of thinking of what the impact of that environment are on the people who work for our organisations.  The debate must be both about how we create resilience in the workplace but also how we create workplaces which require less resilience.

At an annual cost to our economy in terms of lost output of as much as £99 billion and thousands of ruined lives this is not an issue we can ignore.

Martin Luther – A man who changed the world

DSC_2921This Tuesday marks the 500th anniversary of one of the most significant events in European and, indeed, the whole of Western history.  On 31st October 1517 Martin Luther nailed his 95 theses on the power and efficacy of indulgences to the door of the Castle Church in Wittenberg and set in train the set of events which led to the Protestant Reformation, and it could easily be argued, the emergence of western thought and values in the form we know today.

Having studied the Reformation and the 16th century as part of A Level history I took the advantage, earlier this year, to reacquaint myself with the story of Luther, both by visiting Wittenberg as part of my cycle trip on the Elbe and by reading an excellent modern biography of Luther by Scott Hendrix.

In our post religious age the figure of Luther is less familiar than it would have been for most of the last 500 years. Many people would more likely think of the American Civil Rights Leader Martin Luther King than the German religious reformer, although the former was named after and inspired by Luther.  However, whatever one’s approach to formal religion, Luther is a man whose story has a much wider historical and intellectual importance.

Luther is a wonderful example of the interaction between the actions of individuals and the wider forces and trends which generate historical change. In 1517 the ingredients for the Protestant Reformation were all in place.  There was a deep seated dislike of the Catholic Church and, in particular, the corruption of its leadership.  Wider social changes were happening, such as the introduction of printing, which made it easier for new ideas to spread and take hold.  Nonetheless it took the actions of one man to make it happen and, in this case, the actions of that one man over the next 30 years were more than usually significant in influencing events. When I was doing my A level history I came across a wonderful analogy comparing the actions of Luther to Beethoven’s 4th Piano Concerto, where uniquely for that musical form at the time, it was the pianist who played the opening theme on their own before the orchestra joined in.   In the same way in the first years of the Reformation Luther’s personality and actions were crucial in determining what happened.

There were a number specific attributes which made Luther’s contribution so special. He was a brave individual who was prepared to stand up to the most powerful men in the world and stick to his principles under duress and under threat to his life, being forced to spend a year in hiding in the Wartburg Castle in Eisenach. Similarly, while not always prepared to compromise, he had a broader view than many had at the time about how his changes might go with the grain of popular belief. Unlike other reformers he did not argue for the abolition of all traditional practices such as the veneration of images. He was prepared to work with secular supporters while not losing the ability to challenge them.

More than anything else it was his power as a communicator which was at the heart of Luther’s success as reformer. Luther’s written and spoken output, in particular in German, was phenomenal and he out wrote his Catholic opponents by a margin of 2 to 1.  By 1520 250,000 copies of his writing were in circulation, a massive number for the time.   Luther’s communication also embraced a range of forms.  Unlike other Reformers, he believed strongly in the value of music as an adjunct to religious worship and wrote a number of hymns including the famous “Ein feste Burg ist unser Gott.”  We have much to thank him for that as it was the Lutheran tradition which spawned some of the greatest work of J.S. Bach (in one of those lovely historical coincidences they both attended, at 200 years remove, the same school in Eisenach).

Luther has his detractors. He could be an obstinate and angry man.  His views on some issues, in particular the anti-Semitism he expressed in his later writings.    However what also came over from my reading and visit is man of great human warmth, who loved the company of others, who developed strong relationships and partnerships with others.  He was a man who was aware of his own faults and short comings, famously saying of himself “At the same time saint and sinner” and was someone who was acquainted with mental distress, suffering from periods of depression.

Luther, despite the depth of his religious beliefs, struggled in the cold celibacy of the cloister and his marriage to Katharine von Bora was based on a deep and mutual respect for each other and for the comfort and mutual support a married couple can bring each other. Katarina’s comments on Luther’s death are genuine and moving  “If I had owned a principality or empire I would not have felt as bad had I lost it as I did when our dear Lord God took from me, and not only from me but form the whole world – this dear and worthy man.”

At the heart of Luther’s world view is the importance of individuals, all equal before God, all responsible for their own actions and beliefs. This, for me, is Luther’s greatest legacy to western thought and as important today as it was that day 500 years ago when he nailed his 95 theses to the church door in Wittenberg.

 

Why I work in mental health

 

_64128011_de27-1As you will have seen from this blog, I have been concerned, over recent months, in issues about the mental health workforce. The health of the workforce, both in terms of numbers and morale is central to the achievement of any ambitions we have about the development of mental health services. As I described in my last post there are many challenges facing us currently in respect of the workforce.  However as the stigma about mental health begins to recede there are also opportunities to promote working in mental health to a growing body of young people who see mental health as a motivating and central issue in their lives.

For this year’s World Mental Health Day I wanted to respond to this and, with the aim of encouraging others, write about what makes working in mental health for me such an inspiring vocation.

I came into mental health more than 10 years ago, first as Chief Executive at Rethink Mental Illness and subsequently in my current role at the Tavistock and Portman. I had previously had some engagement with the issues while a civil servant and at NHS Direct.  Not everything in those roles in mental health has, like any other job, been brilliant but I do not regret for a moment a decision to work in this field, in particular, at this time.  There are a number of reasons.

Mental Health has been a fascinating area to work in, intellectually.  This relates both to the understanding of the problem of mental illness and its impact on individuals, families and society but also in working on the interventions which might make a difference.    I have been repeatedly struck by the important shadow mental health casts over so many other areas of life:  work, education, the criminal justice system to name but a few, and the prospect of what changes we could make if we recognise properly the burden of mental ill health and invest effectively and prevention and treatment.  Having some role in making the case for change and supporting the delivery of services has been exciting and rewarding.

Mental health is not only intellectually satisfying, it is emotional engaging. Mental health is about people and how they think and how they feel.    The most effective therapeutic interventions I have seen and heard about in mental health rest on the value of empathy and relationships.  Those work in the front line of mental health services understand the direct and powerful role they play, as individuals, in supporting the recovery of the people they are helping.  Those values also matter for those running mental health organisations.

It has also been the right time to work in mental health. It is now ten years ago since the Time to Change programme started in England to challenge stigma on mental health and change public attitudes.  In that decade Time to Change has been the forefront of a sea change in public attitudes which has spread over many areas of public life such as the worlds of business, sport and politics.  With that change in attitudes has come a much greater openness across society about the experience of mental health problems and a greater recognition in all sorts of walks of life of the importance of supporting those affected.  Ten years on it is incredibly uplifting to have had a small part in making that programme happen.  I am unlikely to do anything more significant in my career.

The recognition that this is a special time for mental health also increases the urgency of finding the right things to do to make a difference to lives and collecting the evidence that those things work in practice. That is not easy at a time of austerity when almost any case for investment relies on the ability to make an economic argument that the costs of the new intervention will be, at least, covered by savings elsewhere. Political support may have arrived but there is much work still to do to sceure the necessary resources.

Mental health can be hard in other ways. It has brought me much closer to distress and suffering.  For all the need to be positive and hopeful there are days of profound sadness as when as you hear that someone you have known or are responsible for as a patient has taken their own life.  It has made me more angry than I have ever otherwise been in my career about injustices such the inhuman work capability assessment.

Working in mental health has, I believe, made me a stronger person.  It has opened my eyes to mental health issues outside work and the manifestations of mental health problems amongst my own family and friends.  Working in the field has not made me, necessarily, any better at managing such issues but I hope it has made me more understanding.

The best aspect, however, of working in mental health is the people. In 10 years I have met some truly wonderful and inspiring individuals whether clinicians, researchers, campaigners, service users or family members.  Above all I have met individuals who have experienced tremendous distress in their lives or those of their families but who have been able to direct those experiences towards wanting to make the world better for others.  That’s a great team to be part of.

 

Finding a workforce for the future

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This week saw the publication of an important report from the Mental Health Network on The Future of the Mental Health Workforce for which I was pleased to have been involved in co-chairing the Reference Group.  The report set out some important ideas for how we can deliver the numbers and type of workforce we need in the next ten years.   It came on the back of Stepping Forward to 2020/21, Health Education England’s mental workforce plan, which highlighted clearly and starkly the scale of the challenge (19,000 new members of staff by 2020 and that before we feel the full impact of Brexit) required to deliver the Five Year Forward View commitments and maintain existing services.

We have been pretty remiss over the years in mental health, as elsewhere in the health and care sector, in giving proper attention to workforce issues. They are fundamental, not just to the practical logistics of delivering care, but also to the character and quality of patient experience, most particularly in mental, health where human contact and relationships are at the heart of the therapeutic process.  So I am glad to see a greater attention and focus but, just as importantly, a willingness to think differently about the image, shape and approach of the mental health workforce.

The Future of the Mental Health Workforce highlights a number of important themes which I would like to discuss further in this blog.

The first relates to how we promote careers in mental health to young people. As attitudes towards mental health change and with mental health being so prominent as an issue in the lives of young people there will be a great chance of engaging young people about what a career in mental health might have to offer.  This is not something we have ever done in any systematic way but there is a big opportunity to do so now, starting in schools but also in attracting those who have already enter clinical professions to specialise in metal health – the Royal College of Psychiatrists “Choose Psychiatry” campaign is a great example.

In doing so we need to portray an inspiring but also realistic vision of working in mental health. A serious point of concern, at present, is the rate of drop out of new trainees, insufficiently well prepared for and supported to face the pressures of some of the more challenging aspects of mental health work.  Good quality supervision and mentoring are not a luxury and must be recognised by providers and commissioners as part of service specifications.

Some of the requirements for new staff will come through the creation of new roles such as physician and nurse associates and by the expansion of roles for peer workers, one of the most positive developments in mental health care in the last decade. Similarly some of the issues can be addressed by getting existing staff to take on new extended roles, for instance the training of psychologists to take on roles as responsible clinicians.

New roles are not a panacea however. To work they need new thinking about service models and the role which more experienced clinicians play in supervising and supporting less experienced staff.  They also crucially need new thinking about careers.  As the history of IAPT indicates we can be successful in attracting new entrants to the workforce but we will also need to think how such staff can progress to other roles in mental health or else we run the risk of losing them.

The theme of career pathways is a further important theme. There is, at present, a striking imbalance across the mental workforce.  With 100,000 students registered on psychology courses we have enormous interest in psychology as a profession while at the same time we have significant shortages in other professions such as nursing and psychiatry.  The report, rightly, did not question the importance traditional professional disciplines but highlighted the opportunity in mental health to create much more flexible career paths across professional boundaries and the valuing of core competencies which are relevant in most areas of mental health work.

The issues around careers also apply to older staff. One of the largest challenges for the mental health workforce has been the impact of mental health officer status, a convenient solution to recruitment challenges 30 odd years ago of which we are now seeing the consequences with large numbers of staff taking advantage of the opportunity to retire at the age of 55. As I know from my own organisation is not inevitable that staff near the age of retirement want to leave mental health for good.  Many feel an enormous sense of commitment to the work they do and the patients they serve.  However we are naïve if we expect staff just to carry on with some of the stressful and pressured roles they currently occupy. Even if staff do not want to carry on with existing clinical work there are roles around supervision, mentoring and teaching through which they can use their experience to the benefit of the wider workforce.  There may be also roles in the voluntary sector for instance which offer different opportunities for older staff.  The support and development opportunities we provide for staff in the last third of their careers in considering these choices are crucial.

The last theme of the report and one which resonates with other blogs I have written recently is the need to address and invest in staff wellbeing and resilience.  This needs to be honest about the distressing nature of mental health work and the specific stresses of the current environment.  There are many approaches:  Schwartz Rounds, Balint Groups, Work Discussion Groups which can give staff the opportunity to reflect on their experiences.  If we are to have any chance of avoiding burnout and improving retention their implementation should be a mainstream part of an organisational commitment to promoting wellbeing.

It’s encouraging to see workforce more centre stage in debates about NHS priorities although we need to be sanguine about the scale of challenges facing us in mental health. There are things we can do to turn round the position and we need to be willing to invest where that is necessary to make them happen.  At the end of the day a career in mental health is, at its best, one of the most meaningful and satisfying things you can do.

 

After the case of Kim Briggs we must call time on reckless cycling

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Of the stories I have engaged with in the media this summer few have been sadder than that of the HR Executive Kim Briggs and the subsequent trial of the cyclist Charlie Alliston’s involved in the accident which caused her death.

By any standard this was a tragedy. A young woman has needlessly died and a husband and family have been left without the most important person in their lives.  Such bereavements cast a very long shadow.

The story was especially impactful because it related to cycling in London, something I do every day. Whatever judgements you make about the specifics of what happened, the case was something which should make every London cyclist think carefully about their actions and how their own conduct affects the safety of others who use the roads.

As I have written before about in this blog I am enthusiastic and committed cyclist. Without a question of doubt cycling is the best way of getting about the capital.  It is something to be celebrated that London has become a cycling city with thousands taking to the roads on two wheels and some attempt now being made to make some serious improvements to the cycling infrastructure of the city.  Cycling is good for the environment and good for our physical, and perhaps just as importantly, mental health.  In general, it is something to be encouraged.

However for all the joy I take in the growth of cycling I am also seriously concerned at the culture of reckless cycling which has developed in London. This takes lots of forms from the widespread and in indiscriminate jumping of red lights, the riding of bikes (as in this case) which are unsafe or illegal, to, most distressingly, the reluctance to stop at zebra crossings or show adequate respect to pedestrians.  While sometimes the offences are small scale they all contribute to a culture which leads to poorer road safety and ultimately to a tragic accident such as the one which killed Kim Briggs.  As a community of cyclists I believe I think we need to acknowledge that this culture needs to be challenged and that action is required to raise the standards of conduct by cyclists.

Changing the law, as Kim Briggs’ husband has committed to campaigning to do has its place and I for one would support strengthening legislation to make dangerous and reckless cycling a clearer and more serious offence.

However as we see in other parts of life legislation can only be part of the story and must be supported by a wider public intolerance of dangerous and unacceptable behaviour. Such a view must come most strongly from within the cycling community.

There are three erroneous sets of beliefs which possibly stand in the way.

The first is a belief that cyclists are different and the normal rules of the road do not apply. A very good set of arguments against this view was made by David Shariatmadari in a piece in the Guardian last week.   Cycling can feel a very a natural form of transport but it is not immune from the laws of physics.   In 40 years of cycling I have had 3 serious cycle accidents.  In all cases I was lucky that the only consequence was relatively modest personal injuries but the accidents have made me conscious of how much damage a collision on a bike can do either to ourselves or to another road user.  Those who think they are immortal or who have no regard for other road users have no place on public highways.

The second perspective is the tendency for cyclists, at times, to see themselves as victims.   There are clearly very important issues about how road safety for cyclists can be improved, especially as the numbers of urban cyclists increases.  Some of this is about infrastructure which, while improved, is still inadequate but some of it is also about cyclist skills and behaviour.  The days of cycle proficiency tests may be passed but there is a big case for investment in strengthening the skills of cyclists and to encourage cyclists to see this as a worthwhile activity.  There might be a role for insurers to play a role in offering incentives by reducing premiums for cyclists who have undertaken some kind of training or test of their proficiency.

The third view is that there is a difference between relatively minor infringements such as jumping the odd red light and more serious acts of recklessness. These are judgements which people make in all sorts of areas of life and people feel they can infringe the rules without any obvious risk to themselves or to others.  This is however a dangerous line of thought not only because it contributes to a culture of rule breaking which can give permission to more serious acts but also because if a sufficient number of individuals break the rules it must inevitably increase the risks of a serious incident.

A city as busy as London needs a morality of courtesy, mutual respect and law abiding behaviour if it is to remain safe and a reasonable place to live. We are, as Aristotle famously said, “political animals” a description which refers to our ability to live together in communities and order our actions to the common good.  A saddening feature, at times, of the modern world is to see the achievement of our own short term individual advantage as the most important goal in life. On a bike when we behave like that we will sometimes get away with it but on others it could end up in a tragedy of the kind which befell Kim Briggs and her family. Sometimes it takes a tragedy to change attitudes.  Let’s make sure this one does.

 

Mental Health – The State of Care

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I have just finished reading the very good report produced by the Care Quality Commission (CQC) on the lessons they have drawn from the first round of comprehensive inspections of mental health providers.  Although they may be subject to criticism from time I am a strong supporter of their role in underpinning high quality care and have written about this previously in this blog.  This report is both fair in its assessment of our sector but also challenging about what still needs to be done to deliver the kind of services which people with mental health problems deserve to receive.  It provides a good reference point for my own reflections on the state of care and on the priorities for action.

There is much in the report that mental health providers can take pride in with 74% of core services provided by the NHS and 76% of those provided by the independent sector rated as good or outstanding. This achievement is explicitly acknowledged has having been made against a backdrop of a rise in the quantity and complexity of demand, a product both of positive factors such as the raising of stigma as well as less positive factors such as the reductions in social and community support which have made it harder for people to stay well in the community.  Best of all virtually every service was rated good or outstanding for having caring and compassionate staff.

There is much which those of us working in and leading mental health providers can take pride in but there are also important challenges. In this blog I would like to focus on three.

The first and most significant of these relate to the pressures on the workforce. CQC’s report highlights a 12% fall in the number of mental health nurses between 2010 and 2017 and at present we seem to be losing staff more quickly than we can train them. Health Education England’s recently published Mental Health Workforce Plan makes the scale of challenge even clearer and we need urgent and converted action to address significant gaps in the mental health workforce which would be required to deliver both current services and the new developments set out in the Mental Health Five Year Forward View.  In doing so we are also need to pay attention not just to numbers but also, crucially, to the quality of experience of people working in mental health services.  Compassion and empathy do not grow in a vacuum and we need to be mindful of the intrinsically stressful nature of mental health work.  Systematic investment in good quality supervision and wider initiatives to staff resilience will be crucial and essential if we are to stem a worryingly high level of staff burnout and turnover.

The second issue relates to our ability to deliver, at a time of severe financial pressure, core quality services alongside the new developments set out in the Five Year Forward View. I believe some progress has been made in stemming a tide of disinvestment in mental health services and I strongly support initiatives to promote greater transparency about CCG and other spending.  There needs to be some realism however about the challenge of the task ahead especially where the investment for new developments is predicated on making cashable savings in other parts of the system.  New service developments, welcome though they are, must not come at the expense, either in terms of money or management focus, of the worsening of existing services.  Similarly in area of care where the level of unmet need is so high must we be seduced by overoptimistic assumptions about our ability to manage demand with the danger that we improve access for one group of people with mental health problems at the expense of another.

The third issue relates to inpatient care. As the CQC report highlights this is the part of the system under most pressure and where the incidence of issues around quality is most common.   Every conversation I have ever had on the subject with people who have experienced serious mental health problems, highlights the importance of good quality inpatient care when they need it.  There is no answer to what the right number of beds is for any given area but, again, as the CQC report highlights we have a relatively low level of provision compared to other developed countries and those beds are increasingly full of individuals detained under the Mental Health Act.  The experience we do have suggests that a low level of inpatient provision can work where there is corresponding high levels of investment in community based home treatment services and alternatives to admission such as Crisis Cafes or Recovery Houses.  The quality and skill mix of inpatient provision also matters with evidence that there is a clear correlation between services with a richer skill mix including a strong psychology input and lower lengths of stay.  Many parts of the country will be grappling with these issues as part of their STP plans and it will be crucial this gets the right level of focus if the system is to be capable of managing a continuing growth in demand.  The plans to shift commissioning responsibility for secure and Tier 4 CAMHS services to local level also provides opportunities to shift the balance of care and strengthen the infrastructure of community services.

These are tough times for everyone working in public services. AS CQC’s report highlights the mental health sector has been remarkably resilient given the pressures it has faced.  The challenge to sustain this and deliver the new ambitions set out in the 5 Year Forward View for Mental Health will require strong leadership combined with honesty about what can be delivered within the real resources which are available.  There is some ground for optimism but a hell of a long way to go.