Dear Colleagues
Here in the Peak District, we are starting to enjoy some fine Spring sunshine. Can anyone tell me what breed of sheep is pictured here? They thrive on the Derbyshire hills. Since my Summer 24 Newsletter, which already seems an age ago, we have a Labour government. But no sooner do we have some grown-ups back in charge in the UK, having got rid of a bunch of lying narcissists, than we find ourselves stuck with an even worse bunch in the White House.
Like many of you, I imagine, the spectacle of President Zelensky being shouted at, disrespected and spoken to insultingly in what looked like a pre-planned set-up has managed to plumet new depths of disgrace. After Boris Johnson and Liz Truss exited the world stage as laughing stocks, Trump and Vance have stepped up, it seems, as appeasement fools to Putin.
What this already means is that defence will take priority over health and welfare spending in the government’s immediate priorities. This will make an already difficult policy circle more difficult to square. If economic growth is the primary goal, how come the more we spend on healthcare the less productive our workforce becomes, and it is our benefits bill that grows?
“Reform or Die”, says our Prime Minister to the NHS, apparently without irony, given what is happening to give a boost to Nigel Farage in the polls. There is no more money, insist both Starmer and Reeves, for our new Health Secretary, Wes Streeting. But there is hope:
“… because if we get this right, people can look back and say, this was the generation that took the NHS from the worst crisis in its history, got it back on its feet, and made it fit for the future” (Prime Minister’s speech on the NHS, 12th September 2024).
So, we need to be “fit for the future”. Personally, having been at the centre of the biggest reform in mental health over the past decade and a half – IAPT, I feel a bit like Tony Blair must have felt at the end of New Labour. Looking across the dispatch box at a young David Cameron, with Gordon Brown impatient to take over sitting at his side, he is told by Cameron “you were the future once”. I’ve been to the future for mental health reform, in other words and, as Blair reflected on his reforms, got “the scars to show for it”. Real change is not easy.
Hearing all the talk now about the transformative power of AI, I am reminded of what prompted me to get involved in mental healthcare reform some two decades ago, in 2005. An edict came round from the Mental Health National Tsar, (the now Sir Louis Appleby), instructing our GP Practice on Coldharbour Lane, Brixton, to install Computerised CBT. Patients could then access the treatment that NICE had decided was the most cost-effective for depression. The Primary Care Trust had duly bought all its mandated licences, so there was no more money left. The GP Partners found an old computer and put it in a corner of the waiting room with a chair and a table for any patient who cared to use it. No one did. Without staff support to explain how it might benefit them, show them how to use the programme and then monitor their progress, it was a total waste. ‘Surely there must be someone in charge who knows better than this?’, I thought to myself, and so I turned up to my first APP meeting.
Ronnie Doctor had just stepped into the role of Chair. ‘What are we going to do about NICE guidelines?’, I asked from the floor, ‘because if we do nothing, psychoanalytic psychotherapy as ‘a future hope for NHS mental healthcare’, once upon a time, will all too soon disappear.’ Ronnie’s reply echoed a time when US Presidents put public service, not personal profit, first: “Ask not what the APP can do for you, ask what you can do for the APP” (John F. Kennedy). It is a question I want to put back to you all, as our members, and particularly our newest cohort of Registrant members, who are taking advantage of our status as an MI within BPC. Over coming weeks and months we shall be reaching out to you to have these conversations.
Thanks to the work we have done in APP over the last 2 decades the existential risk that psychoanalytic psychotherapy may disappear from the NHS has been met by securing a place in the 2022 NICE guideline for depression – which will be at the heart of what gets delivered within the forthcoming NHS 10-year plan. Added to this, there are a number of exciting new developments in evidence-based psychoanalytic treatment for much more complex issues, including results from a large-scale RCT for antisocial personality disorder, led by our former journal editor Jessica Yakeley, along with the well-loved double-act of Bateman and Fonagy.
In this report I want to take a look at the reform agenda of the Labour government, given that with or without any money, they have a Parliamentary majority that enables them to pass new legislation. What is on their near horizon? Several areas of policy intersect with the work of psychoanalytic psychotherapists in publicly funded services. Whilst none of these are existential, in fact, none are either threats or opportunities in themselves, how they play out – and whether we can influence that – will shift the landscape of possibilities for clinical work. There were two new pieces of legislation promised in the government’s Kings Speech 2024 last July, namely, a new mental health act that will seek to deliver on Professor Sir Simon Wessely’s review back in 2018; and a draft bill to ban conversion therapy that will also deliver on what the Tories had promised to do but didn’t. Both are complicated policy issues.
In addition to these new laws there is the proposal for a law to support an assisted end to life. As everyone knows, Freud is said to have agreed some kind of arrangement with his doctor, Max Schur – namely, what some prefer to call an ‘Assisted Suicide’. There are opposing views that stress on the one hand the concepts of dignity and autonomy, and a humane limit to prolonged suffering; and on the other hand, the duty to support life and relieve someone’s despair alongside alleviation of pain, such as in the hospice movement and with palliative care. Last September, our Older Age Special Interest Group convened by Dr. Funmi Deinde met to discuss a moving, thoughtful paper by Julia Segal on her work with a couple where one partner faced the end of life. It will be interesting to see whether the arguments in favour of autonomy, dignity and choice that sit at the heart of the mental health Bill, come under scrutiny now from those opposed to Assisted Dying, in case they set a precedent for the latter.
We hope to revisit this subject again as the Bill sponsored by Kim Leadbetter MP progresses. But we should also consider implications of the Mental Health Bill. Could any members who have an interest in either issue get in touch, please, so we can sponsor a discussion.
Even more polarised, though, are the arguments around healthcare for young people with gender dysphoria. As everyone will know by now the report by Hilary Cass recommended closure of GIDS, the service run from the Tavistock and Portman clinic. But what next? A trial to test whether the benefits of puberty blockers outweigh their harms, funded at £10.7M, has been awarded to a team led by Professor Emily Simonoff at Kings College. How will it establish clinical equipoise between the different intervention groups, allocated randomly? In 2011, some 200 young people under the age of 18 were recorded by GPs as identifying as transgender. Ten years on, some 10,000 were recorded. This remains one of the unanswered questions from the Cass Review. Why? Should we understand ‘trans’ as a form of what the late Ian Hacking referred to as ‘transient mental illness’, given that for the majority of young people it does seem to be something like that? Or should we accept that ‘trans’ can be what I would call a stable, ‘naturally constructed’ kind of identity that deserves therapeutic support?
The battle lines appear to be so firmly drawn that it is difficult to see how the government’s Bill to ban conversion practices can reconcile them – and not any time soon, I would guess, since the Minister of State, Annaliese Dodds, has just resigned from the government over their cuts to international aid to fund defence. ‘Events, dear boy, events’ – Harold MacMillan. I hesitate to put out a call for expressions of interest in setting up an event to discuss the conversion practices / gender dysphoria problem but, in the spirit of MacMillan, I will.
*NB Our Registrant members should note that Standard 5 is a compulsory standard in their BPC Code of Conduct, (which comes into effect this April). It states:
You must not offer, practise or advocate conversion practices.
This means that anyone who is found in breach of this requirement is at risk of being removed from the Register and declared unfit to practise. On July 15th, I have agreed to give a talk as part of David Morgan’s Political Mind series, where we will discuss this in detail.
Some reasons that the NHS will reform, not die, and some hope for psychoanalytic psychotherapy …
The starting gun for the new government’s reform agenda for the NHS was fired by Lord Darzi’s report. For now, I will just make a few brief points, and some predictions for what “reform or die” will and will not mean under what looks like a rather ‘old-style’ new Labour government that is yet, thankfully, to promise ‘cheerfulness’ (as New Labour was persuaded to promise, thanks to Lord Layard) as a panacea cure for the nation’s mental health problems.
What did the Prime Minister mean by positing it was either reform or death for the NHS?
- To suggest the NHS might somehow be allowed to ‘die’ is, obviously, utter nonsense. But what it signals is ruling out significant additional investment as the ‘easy answer’ for this budget. Nevertheless, it is an iron law that Labour will end up spending more.
- The LibDems are, in effect, the official opposition party now that the Conservatives are entering the final stage of their own ‘Reform or Die’ melodrama. Astutely, for a change, the LibDems have positioned themselves as the party of NHS and social care investment – calling for an extra £4.8bn to fund NHS running costs and capital spend.
One interesting new development here is the election of Layla Moran as the Chair of the cross-party Health and Select Committee. Most of the policy problems facing the NHS cannot be fixed without also fixing social care. That needs cross-party support.
- Despite the fact ring-fenced funding to expand mental health has proven to be what the Treasury fears for the whole of NHS funding – a bottomless pit with no return – mental health will be a beneficiary of its own failed reforms. Why? For two unavoidable reasons – which Starmer’s speech on the NHS almost entirely ducked:
- Sitting at the top of Dr Adrian James’ in-tray (he is our new National Clinical Lead for Mental Health and Neurodiversity), once again, is public safety. The system failed Valdo Calocane, who was suffering from paranoid schizophrenia for three years, twice discharged from hospital, but clearly very unwell, until he tragically killed three people: two young Nottingham University students, Grace O’Malley-Kumar and Barnaby Webber, starting out on adulthood with everything to look forward to, and Ian Coates, a 65-year-old school caretaker, on the verge of enjoying his retirement with his family and his grandchildren.
These deaths were avoidable, as was the death of Jonathan Zito, more than thirty years ago, attacked and killed on the platform of Finsbury Park tube station, by Christopher Clunis, who was failed by the mental health system, and who died recently in 2021. Darzi states – or understates, conscious of potential for the media to ignite a moral panic: “there are also concerns about the rigor with which patients who have serious mental illnesses are followed up in the community and how effectively risk is managed.” (p. 47).
For those who have not seen it, the moving Panorama programme[1] shows how the family of Calocane, his mother and brother, were failed by our system, just as much as the families of the victims. Mental health is given ‘parity’ of policy only whenever public safety is threatened. The families of Calocane’s victims are not going away, and will continue to demand accountability. Earlier this month, a judge-led public inquiry was announced. Will its findings, as well as a new mental health act, prevent any future such tragedies? Probably not. But they will provide an opportunity for understanding the kind of reform needed.
- In August last year, the Times columnist and former Tory MP, Matthew Parris, continued his polemical attack on mental health: Mental health industry is cheating the public (August 19th). He only needed one statistic: there are 9 million people out of work. Starmer cannot avoid this fact – spending on welfare benefits now amounts to spending on the whole of health and social care. So how come the more we spend, the sicker we get? Lord Darzi points to the 2.8M people on long-term sickness benefits, stating “it is our mental health that appears to have deteriorated most significantly in the past decade” (p. 19). Cheating or not, mental health sits at the intersection of rising public spending. If there is any doubt about this, watch conservative journalist, former editor of the Spectator, Fraser Nelson, and his investigation for Channel 4 Dispatches:[2]
“There seems to be a bit of a pattern amongst those I spoke to. They were all working, life seemed to be going pretty well for them, but then a mental health episode knocked them for six. Now that’s actually not unusual. About two thirds of those who apply for sickness benefits mention anxiety, depression or something similar. But instead of being given the help they need to get back into work, they get sucked into a benefits system from which they’re unlikely ever to emerge.” Fraser Nelson, 02.12.24, Channel 4 Dispatches.
Two decades ago, David Freud, now Lord Freud, great grandson of Sigmund, recently retired from investment banking, was asked to investigate ‘the Welfare Trap’. You can read about his reform proposals that brought into being Universal Credit as the solution implemented by the Coalition government.[3] If you are interested, you can also read about my own experience working with David Freud and Richard Layard, and why they failed to solve the problem, in my article in the International Journal for Applied Psychoanalytic Studies.[4]
This failure might seem an odd reason for us to be cheerful. But the fact is that talking therapies are now seen as indispensable to solving the intractable problem of growth, and why Darzi singles out, amongst the litany of things that are broken (345,000 patients on waiting lists for mental health treatment for more than a year!), “a notable success in the Improving Access to Psychological Therapies programme” (p. 44). In other words, expanding the NHS Talking Therapies workforce will continue under Labour. Another Adrian – Dr. Adrian Whittington, National Clinical Lead for the Psychological Professions at NHS England – talks of doubling the size of the talking therapies workforce in the next decade. Who will be making the case for additional psychoanalytic psychotherapy trainings and posts within his plans?
That is a question for today’s psychoanalytic leadership. Whether anyone is interested in the experience of a ‘failed’ reforming National Adviser who was ‘the future once’, I will leave you to speculate on with my analogy with Tony Blair – betraying, in eyes of my critics, no doubt, my delusions of grandeur!
Before the sun sets on a previous era of mental health policy, though – and who could have guessed that we would be gifted Nadine Dorries as our Minister for Mental Health by Prime Minister Boris Johnson? – I will leave you with the most cheerful part of Lord Darzi’s review:
“Accountability is important. But too many people holding people to account, rather
than doing the job, can be counterproductive … Taken together, there are nearly 80 people employed in regulatory and headquarters functions for each NHS provider trust. And there are a multitude of other organisations that produce guidance, recommendations and standards. NHS organisations should focus on the patients and communities they serve, but the sheer number of national organisations that can ‘instruct’ the NHS encourages too many to look upwards rather than to those they are there to serve …” (pp. 10-11).
And with one sentence, Darzi will have earned the lifetime gratitude of many NHS clinicians: “The Care Quality Commission – which inspects the NHS – is not fit for purpose” (p. 11).
The sun sets behind the hills of the Longdendale valley, as the tenure of Nadine Dorries, former Minister for Mental Health under Boris Johnsons, fades into a distant memory
Jeremy Clarke, Chair
[1] https://www.bbc.co.uk/iplayer/episode/m0021zn9/panorama-the-nottingham-attacks-a-search-for-answers#xtor=CS8-1000-%5BEditorialPromo_Box%5D-%5BNewsEditorial_Promo%5D-%5BNewsEditorial_Promo%5D-%5BPS_IPLAYER~N~m0021zn9~P_PanoramaNottinghamAttacks%5D
It should be noted that Panorama did not speak with the families of the three people who were killed.
[2] https://www.youtube.com/watch?v=hVQZdjBu20k&t=99s
The individual case examples that the programme starts off with are all common mental health problems.
[3] Freud, D. (2021) Clashing Agendas: Inside the Welfare Trap London: Nine Elms Books Ltd.
[4] Clarke, J.C. (2023) A new deal for dynamic psychotherapies: The psychoanalyst as street-level bureaucrat. Int. J. Appl. Psychoanal. Studies 1-32
