In 2004 I completed a degree in mental health nursing and began work on a psychiatric acute ward near to my home in Bristol. Clifton Ward in Southmead Hospital had 19 beds, was always fully occupied, and provided care for people with a range of illnesses, including schizophrenia, bipolar affective disorder and major depression. Many of the patients stayed on a voluntary basis, others were detained under the Mental Health Act – commonly known as being “sectioned”.
The ward could be chaotic at times, with smashed doors and flying furniture. It could also be a quiet place, still and heavy with sadness. To serve Christmas dinner to a person who has nowhere else to go, but who believes she is being “eaten alive in this place” holds a quality of sadness that I think exists only within the mental health system.
But for all its inherent trials, what I remember most about my time on Clifton Ward is that we helped people. People trapped in awful suffering at the start of an admission would be markedly improved by the time they left us. There is much to be said for the simple provision of respite – a safe, warm place to be away from the stresses of life. We also offered medication; social work support to help people deal with defaulted bills, missed rent and other such complications that so often accompany a serious mental breakdown; and an occupational therapy programme, including walking groups and art groups.
In short, we were able to offer full and extensive care packages, making a real difference to people’s lives.
I’m not suggesting that it was perfect; mental health has long been the Cinderella service of the NHS, and resources, even then, were stretched. We needed more staff, and more time devoted to talking therapies over pharmaceutical ones. The place could have done with a lick of paint and some new felt on the pool table. No – it wasn’t perfect, but it wasn’t bad. It was a safe place where very sick people could take their first supported steps towards wellness.
After three years I felt ready for a new challenge. I left the “front line” and took up a research post at the University of Bristol, to spend more time looking at numbers: of those who attempt suicide 1% complete within a year, and more than 5% after 10 years. A history of attempts is the strongest predictor of eventual completion. That sort of thing.
I might never have set foot on Clifton Ward again, except in the summer of 2011 my best friend attempted suicide.
Byron Vincent is a writer. We first met eight years ago when he moved to Bristol from his home in Lancaster. We were involved in the performance poetry scene, and soon found ourselves sharing the bill at gigs across the country. We began to write and work on shared projects, have toured the festival circuits together, and became close friends along the way. I knew that Byron had a diagnosis of bipolar affective disorder, and I knew he’d been very unwell in the past. But this wasn’t something we talked too much about, and neither did we talk about my work in this field. These weren’t the things our friendship was built on.
Byron’s breakdown in 2011 was no bolt from the blue. And I believe it could have been prevented. His health had been deteriorating for months. Withdrawing socially, unable to sleep or concentrate – he was moving into a very dark place.
His other friends and I did what we could, and part of what I could do was reacquaint myself with old colleagues. I would make daily phonecalls to his community psychiatric team, and also to a specialist service in Bristol called the Crisis team, or maybe it’s the Home Intervention Team – there is a heck of lot of rebranding in this sector of the NHS. This service essentially holds the keys to all of the inpatient wards, meaning that requests for informal admissions must go through them. They have an incredibly difficult job, balancing risk with the availability of beds.
In the four years since I’d hung up my alarm fob and drugs trolley keys for a quieter life in research, the threshold for inpatient admission had been rising steadily higher. Beds had started closing down, meaning patients now needed to be more unwell to get offered one, and at the other end of the process were being discharged sooner – before meaningful recovery.
For all that, my memory of the ward was of a good place. Somewhere Byron could touch the ground without breaking, and start to rebuild. I had faith it could offer respite. When I was first nursing there was still such as thing as a planned admission; a structured stay in hospital to prevent a crisis. That’s unimaginable now.
My phone calls didn’t achieve anything; it took an attempt on his own life before Byron was finally offered a bed. When he texted me to say where he was I quickly arranged a visit – my first to the ward in four years. Byron has a longer‑term perspective. “It had been 18 years since my last holiday in the concrete bosom of an NHS psych ward,” he told me as we set about writing this article. “Back in the early 1990s wards looked pretty grim, aggressive 70s wallpaper patterns peeped through decades of mottled nicotine. These days everything is magnolia and smells of bleach. Last time, patients shared a mixed dorm with only thin blue curtains separating the chorus of nocturnal noises. This time everyone had their own room.”
So that’s good, right? A clean ward. Your own room. The only problem: Clifton Ward was about to shut down. Byron had arrived just weeks before a long-planned closure. “Job losses were imminent,” he told me. “The tension was palpable.”
That was my impression too. During visits to see him I’d get a rare chance to catch up with people I used to work with. These were good nurses, excellent professionals. Only now they were exhausted, pissed off and worried about their futures. These are difficult times to be a nurse and worse still to be a patient. After a few days Byron was transferred to the adjacent ward, not for clinical reasons but as part of the staggered closure of beds. I hoped that here he would find a more stable environment – only this ward was slated for closure too. It’s a trend that continues in earnest, and not just in Bristol but across the UK. Since Byron’s admission to hospital in 2011 there has been a further 9% reduction in mental health beds across the NHS – that’s more than 1,700 closures. Ten years ago there were 32,000 mental health beds in England and Wales, that has now fallen by almost half.
In other news: the population continues to rise, meaning that the pressure on remaining beds is greater than ever. This week the government unveiled its “mental health strategy”, including new rights for patients to choose the consultant who will oversee their care. This at a time when bed shortages are so critical that there are now frequent cases of unwell people being sent hundreds of miles from their homes. We’re nowhere near being able to choose our doctor; we’re lucky if we get to pick the city we’re treated in. The government’s rhetoric appears baseless.
Up and down the country care-givers are faced with redeployment or enforced reapplications for their own jobs. This uncertainty and the stress it causes affects our ability to offer quality care. “Back in the day,” Byron told me, “staff and patients would sit together in the common room playing cards and chewing the fat. In this place there was a clear delineation, most attempts to chat to my care-givers were met with an efficient brush-off.”
Part of me recoils at this and wishes to contradict him. I feel protective of my profession, somehow. Of my own clinical practice. But that’s hardly the point, is it? It’s the patient experience that matters. Byron’s take: “The modern system seems much more focused on bureaucratic risk avoidance than it is on care.”
Management of risk is a legitimate part of our work – it was, of course, precisely why Byron got admitted in the first place. The safety of patients (and the public) is paramount. In the crudest terms – we can’t enter into a therapeutic relationship with dead people. But it’s this therapeutic involvement where Byron, and so many other users of mental health services in the UK, feel most let down.
So where are we going wrong?
We’re not just losing beds to the cuts, we’re losing staff. When I first qualified we ran shifts on greater numbers; more nurses and more care assistants. With enough feet on the ground we can manage security, medication, ward rounds, mental health tribunals, multi-disciplinary team meetings, the ever-increasing paperwork – and still have time to sit and talk meaningfully with the people who use our services. Or better yet, walk and talk. Psychiatric wards can be pretty claustrophobic places. Byron was desperate for some leave. “Some days a nurse would ask me if I wanted to go for an escorted walk the following day,” he told me. “I always said yes but it never happened.”
There weren’t the staff to take him. In the end, myself and my girlfriend (also a mental health worker) took Byron out for dinner. He remembers it: “Even though they knew you and were aware of your training, it took ages to persuade them.” The newly qualified nurse-in-charge wanted – quite rightly – to fully assess the risk. Byron’s status on the ward was voluntary, meaning that legally he was well within his rights to leave at any time, accompanied or otherwise. But this can be a murky area, as Byron explained: “When I suggested I was going to leave or go for a walk it was made clear to me in no uncertain terms that I’d be restrained until they could have me sectioned. I was only a voluntary patient in name.”
This is a troubling notion, and it is not the first time I have come across it. Clearly, best practice dictates that if a patient is deemed unwell enough to be assessed for detention under the Mental Health Act then this assessment should occur. The kind of “holding powers” that Byron is referring to are in place as an emergency measure, not to dangle over a patient as a negotiation tool. For a person to remain “voluntary” with the looming threat of detention should they try to leave, effectively incarcerates them – but without any of the rights (for appeal, legal aid etc) that the Mental Health Act provides.
On this occasion the nurse arrived at the right decision. We took Byron out. We ate steak. We returned to the ward. For patients who are sectioned the low staffing levels are presenting another problem, which I believe amounts to an institutional neglect. This is a bit technical, but put briefly: if a detained patient requires leave from a ward, even for a very brief period, this must be written up in advance by their consultant psychiatrist. It’s called “section 17 leave”. Often a person won’t be well enough to go out alone so their section 17 might prescribe: half an hour ground leave per shift, with nursing escort. There are sheets of paper stating this in hundreds of wards all over the country. The problem is that often – worryingly often – there aren’t the staff available to offer that escort.
I consider this scandalous. The Mental Health Act is about rights, not merely restrictions. It is my opinion that if a person is written up for escorted leave then it is the NHS trust’s duty to ensure this can be facilitated. For an unwell person to have a piece of paper explaining that they are allowed some time out of the maelstrom only to be told it is not practically possibly, but maybe tomorrow – that’s torture.
Mental health care in the UK is in an utter, God-awful mess. Don’t take my word for it. Last year Dr Martin Baggaley, medical director at South London and Maudsley NHS Trust said: “We are in a real crisis. I think currently the system is inefficient and unsafe.” Care minister Norman Lamb admitted: “There is an institutional bias in the NHS against mental health.”
Byron’s take from the coalface: “There was a pervasive air that things were disintegrating, one day I found a member of staff hiding in a bush. Alarms would sound and not be switched off for hours. The ward was more a place of crisis management than one of respite. I really felt for most of the staff, it was obvious they were doing their best under what were clearly incredibly difficult circumstances”
It is two and a half years since Byron left hospital. We continue to write and work together. In May he’ll be best man at my wedding. For all the failings of the system he got that bed. His most basic needs were met – a safe place to sleep, some food in his belly.
But what about next time? It’s not a thought I like to contemplate, but I can hardly breathe a sigh of relief. What about those suicide statistics? What about the continued bed closures? There were 18 years between my friend’s two stints in hospital. In another 18 years, one way or another, things will look very different. Quite how is in the hands of those who control the purse strings. What I am convinced of, however, is that right now we are moving in entirely the wrong direction. We are failing the most vulnerable of our society.
Byron Vincent will appear at the RSC on 9 February. His show about bipolar disorder, Talk About Something You Like, will be at the Edinburgh fringe before touring. Nathan Filer’s The Shock of the Fall is the winner of the Costa first novel award.
Mental health care: the place did it all go so incorrect?
