There are many ways of trying to make sense of tragedies involving people with severe mental illness (Nottingham attacks: series of errors led to Valdo Calocane being discharged, review finds, 12 August). Calls for new guidelines, changed legislation, and improved “risk assessment”, while well-meaning, are unconvincing, not least because that’s what’s been happening since the Clunis report 30 years ago. They miss how complex and profound the problems are.
NHS clinicians operate in a context of rationing and scarcity, gaslit by their own organisations with talk of “efficiency savings”, “flow” and “productivity”. This can sound an awful lot like the problem is with staff who are slow, lazy and inefficient. The service values high “churn” and rapid discharge, viewing every inpatient admission as a failure of community care.
On top of this sit highly fragmented services, which can shield clinicians from seeing the consequences of their decisions as the patient moves from one team to another. Still further is an ideological attachment to respecting patient autonomy that spills over into the respecting of autonomies highly distorted by psychotic illness, where the patient is certain there is nothing at all wrong with them; psychosis often involving a seductive invitation to collude with this denial.
Practising careful, thoughtful psychiatry in this context is extremely difficult. Over time, clinicians (GPs as well as mental health staff) begin to have the experience of rarely seeing a person with psychosis get better. They start to believe that the patients are untreatable or are unable to benefit from services. And, of course, this makes premature discharge still easier. You cannot legislate your way out of what is fundamentally a problem of resources and a deeply rooted distorted culture.
Dr Simon Wilson
Consultant psychiatrist, London
• I have just retired after 30 years as a consultant psychiatrist working in a community mental health team. Let me provide you with some context for the tragic events in Nottingham. Mental health services everywhere are under severe pressure after years of neglect and cuts. There are not enough inpatient beds, so it’s difficult to admit people who are very unwell, even when detained under the Mental Health Act, and inpatient teams have to discharge quickly to poorly-staffed community teams.
There is a lack of trained staff, money and social resources – all the result of repeatedly broken promises. Community mental health teams are particularly affected as they are right in the middle of this. The jobs are high pressure, exacerbated by understaffing and rising demand. It is impossible to work to a good standard.
This context is always absent from any locally focused review following any shocking incident. Staff working on the frontline are acutely aware that they will be “held to account”, yet they are in an impossible bind and understandably are tempted to manage the tension by turning away – by discharging patients they do not have the resources to effectively help. You’d have to be superhuman not to become demoralised by the situation. Can we be surprised that staff are leaving and it is impossible to replace them?
Dr Geoffrey Searle
Bournemouth
• Anybody with experience of either working in mental health or having recovered from severe psychosis knows that the world of the sufferer is completely dominated by delusions and hallucinations which may, in some cases, cause the individual to engage in violent behaviours that they would never engage in when well. Severe paranoid psychosis is not something that the sufferer is able to control without skilled and assertive therapeutic intervention, so often sadly lacking within our current mental health services.
I have every sympathy for the victims in this case and the relatives of those who lost their lives. I also feel sympathy for the family of Valdo Calocane and for Calocane himself. They have also been severely let down by mental health services and have to live with the consequences for the rest of their lives. They are also victims and deserve our understanding and compassion.
Lin Bigwood
Retired mental health nurse, Bristol
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